Catheter ablation and clinical outcomes in octogenarians with paroxysmal atrial fibrillation

Background Patients aged ≥80 years represent a relatively high-risk subgroup of the atrial fibrillation (AF) population and particularly remain underrepresented in randomized trials evaluating catheter ablation (CA). Therefore, current evidence regarding the association between CA and clinical outcomes such as ischemic stroke and mortality in this population is limited. Methods We performed a retrospective, propensity-matched, observational study using the TriNetX Research Network to identify patients aged ≥80 years with paroxysmal AF (PAF) between 2010 and 2024. Patients undergoing CA were compared with a procedurally eligible control cohort. The primary outcomes were ischemic stroke and all-cause mortality assessed between 90 days and 1 year following the procedure. Secondary analysis evaluated de novo ischemic stroke after excluding patients with prior stroke. Peri-procedural safety outcomes occurring within 30 days of ablation were assessed in a separate analysis comparing octogenarians with a younger cohort of patients who underwent CA. Time-to-event analyses were performed using Kaplan–Meier methods and Cox proportional hazards models. Results After matching, 1,432 patients were included in each cohort with well-balanced baseline characteristics. CA was associated with significantly lower rates of ischemic stroke (3.86% vs. 7.30%; HR: 0.52, 95% CI: 0.37–0.72; p = 0.0001) and all-cause mortality (2.97% vs. 8.05%; HR: 0.36, 95% CI: 0.25–0.52; p < 0.0001). In patients without prior stroke, CA was also associated with a lower incidence of de novo ischemic stroke (1.49% vs. 3.13%; HR: 0.466, 95% CI: 0.26–0.84; p = 0.0092). Peri-procedural complication rates were low and did not differ significantly between octogenarians and younger patients undergoing CA. Conclusions In a large real-world cohort of octogenarians with PAF, CA was associated with significantly lower risks of ischemic stroke and all-cause mortality beyond the peri-procedural period, without an associated increase in short-term procedural complications. These findings support consideration of CA as a viable rhythm-control strategy in elderly patients.