Baseline multidomain atrial vulnerability stratifies recurrence after AF ablation in elderly patients

Background Recurrence after catheter ablation for atrial fibrillation (AF) remains frequent in elderly patients, despite contemporary techniques. Conventional pre-procedural assessment relies primarily on AF type and atrial size, potentially underestimating the complex interplay of structural, electrical, and systemic factors contributing to multidomain atrial vulnerability. Purpose To identify independent baseline predictors of 1-year AF recurrence in patients aged ≥70 years undergoing first-time ablation and to integrate them into a pragmatic multidomain vulnerability framework to refine risk stratification. Methods We prospectively enrolled 122 consecutive elderly patients undergoing index AF ablation. Patients with reduced systolic function were excluded. Baseline assessment included clinical comorbidities, NT-proBNP, comprehensive echocardiography with left atrial volume index (LAVI) and left atrial reservoir strain, and 24-hour Holter-derived premature atrial contraction (PAC) burden. Recurrence was defined as AF/atrial tachycardia/flutter ≥30 seconds beyond a 90-day blanking period. Independent predictors were identified using multivariable Cox regression analysis. An additive 8-item multidomain vulnerability profile (1 point per independent predictor) was constructed. Patients were stratified by tertiles, and recurrence-free survival was compared between lowest and highest tertiles using Kaplan–Meier analysis. Model discrimination was assessed using the C-statistic. Results During 12 months of follow-up, 59/122 patients (48%) experienced recurrence. Independent predictors included heart failure, chronic kidney disease, obstructive sleep apnoea, longer AF duration, higher NT-proBNP, larger LAVI (per 5 mL/m² increase), reduced left atrial reservoir strain (per 5% decrease), and higher PAC burden. Hazard ratios demonstrated graded risk, with stronger associations for heart failure and CKD than for AF duration and PAC burden. Electrical and structural markers contributed complementary prognostic information. The model showed strong discrimination (C-statistic 0.82). Kaplan–Meier analysis demonstrated marked separation, with 79.3% recurrence-free survival in low-risk patients (n=29) versus 22.2% in high-risk patients (n=27) at 12 months (log-rank p < 0.001). Conclusion In elderly patients, AF recurrence after ablation reflects cumulative multidomain vulnerability rather than atrial size alone. Reduced left atrial reservoir strain independently predicted recurrence, highlighting the role of atrial mechanical dysfunction, while Holter-derived PAC burden underscored the contribution of electrical substrate. Together with systemic comorbidities, these findings support a multidomain baseline framework to improve risk stratification and candidate selection.Figure 1.AF recurrence predictors, CoxFigure 2.