Ablation efficacy and safety in elderly vs. super-elderly with atrial fibrillation: insights from the prospective multicenter REAL-AF registry

Background Catheter ablation(CA)for atrial fibrillation(AF)is increasingly performed in older adults,yet contemporary data in elderly patients remain limited,particularly regarding the trade-off between rhythm outcomes and procedural safety. Purpose To evaluate and compare the efficacy and safety of first-time CA for AF in elderly patients. Methods Elderly patients(≥75 years)with AF undergoing first-time CA in the prospective,multicenter REAL-AF registry(2018–2024)were included and stratified into 75–84and ≥85 years groups.Follow-up was up to 459 days,with administrative censoring at the same timepoint.The primary outcome was atrial arrhythmia recurrence occurring >90 days post-ablation.Secondary outcomes were major adverse events;timing analyses were restricted to events with documented dates. Results A total of 2,541 elderly patients were included:2,429(95.6%)aged 75–84 years and 112(4.4%)aged ≥85 years.Other than age,baseline characteristics were largely comparable between groups(75–84years vs ≥85years),including sex distribution,AF type and prevalence of hypertension,heart failure,prior stroke/transient ischemic attack(TIA)and vascular disease(all P>0.400).Median time from AF diagnosis to ablation(1.0[0.0–5.0]vs2.0[1.0–5.0]years;P=0.600) and procedural strategy(pulmonary vein isolation-only:24.8%vs27.7%;P=0.500) were similarly comparable. At 12-month follow-up,repeat ablation(4.4%vs2.7%;P=0.600) and antiarrhythmic drugs modification rates(changes:6.1%vs5.4%;P=0.700;start new:2.9%vs1.8%;P=0.800) were low and comparable between groups. In Cox proportional hazards analysis clustered by physician,age ≥85 years was not independently associated with recurrence >90 days after ablation in either unadjusted(HR0.73,95%CI 0.49–1.09;P=0.120) or multivariable-adjusted analysis(aHR0.72,95%CI 0.49–1.08;P=0.110). In contrast,female sex(aHR1.38,95%CI 1.14–1.67;P<0.001) and persistent AF(aHR1.36,95%CI 1.14–1.62;P<0.001) emerged as the dominant independent predictors of recurrence.Overall adverse event rates were 5.0%;among events with documented dates,89.5% occurred within 30 days,6.6% between 31–90 days and 3.9% within 91–459 days.Major adverse events(TIA/stroke/bleeding/death) were largely concentrated within 30 days(94.4%),with death(including procedure/device-related)accounting for the majority(2.8% overall).Adverse events were more frequent in the ≥85 group(any:4.9%vs 8.9%;major:3.2%vs 8.0%),driven primarily by higher mortality captured during follow-up(2.6%vs 7.1%). Conclusions Among elderly patients(≥75 years)in the REAL-AF registry undergoing first-time AF ablation,super-elderly(≥85 years) was not associated with higher >90 days atrial arrhythmia recurrence,with female sex and persistent AF as the dominant determinants.However,adverse event and mortality rates were higher in the ≥85 group,highlighting the need for individualized decision-making over age thresholds in elderly AF ablation.