Combined impact of diagnosis-to-ablation time and left atrial volume on one-year recurrence after first pulmonary vein isolation

Background Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with impaired quality of life, heart failure, and thromboembolic events. Catheter ablation, particularly pulmonary vein isolation (PVI), is an established rhythm-control strategy and a cornerstone procedure for AF management. Despite advances in ablation technologies, post-ablation recurrence remains a major clinical challenge. A prolonged diagnosis-to-ablation time (DAT) and left atrial (LA) enlargement are each associated with recurrence after catheter ablation, reflecting progressive atrial remodeling. However, it remains unclear whether combining DAT with the LA volume index (LAVI) can identify a distinct high-risk subgroup following first-time PVI beyond either factor alone. Purpose To evaluate the association of combined DAT and LAVI with one-year AF recurrence after first-time PVI. Methods This single-center retrospective cohort study included consecutive patients undergoing first-time PVI (radiofrequency or cryoballoon). Patients were categorized into four groups based on DAT (<1 vs ≥1 year) and LAVI (<42 vs ≥42 mL/m²): S/L Group (short DAT/low LAVI), S/H Group (short DAT/high LAVI), L/L Group (long DAT/low LAVI), and L/H Group (long DAT/high LAVI). The primary endpoint was AF recurrence, defined as documented AF between 90 days and one year after the procedure (excluding the blanking period). Kaplan–Meier analysis and Cox proportional hazards model were performed. The primary multivariable model adjusted for age, sex, hypertension, and heart failure (factors commonly linked to recurrence). Sensitivity analysis additionally adjusted for AF type (paroxysmal vs non-paroxysmal). Results A total of 473 patients were enrolled (median age 68 years [IQR 59–75], 29.8% female). Baseline characteristics varied across the four groups, including AF type, hypertension, heart failure, CHA2DS2-VASc score, and left ventricular ejection fraction. During the one-year follow-up, 54 recurrences occurred after the 90-day blanking period, and Kaplan–Meier curves showed significant differences across groups (log-rank P=0.0025) (Figure). In the primary multivariable Cox model, L/H Group had a significantly higher risk of recurrence compared to S/L Group (HR 2.26; 95% CI 1.14 – 4.50, P=0.02), S/H Group (HR 2.90; 95% CI 1.36 – 6.17, P=0.01), and L/L Group (HR 2.82; 95% CI 1.27 – 6.27, P=0.01). Conversely, no significant differences were observed among S/L, S/H, L/L Groups. Findings remained consistent after additional adjustment for AF type. Conclusion Prolonged DAT combined with enlarged LAVI identifies a subgroup at high risk of recurrence after first-time PVI.