Apparent Recurrence Differences between Paroxysmal and Persistent Atrial Fibrillation after Catheter Ablation Are Attributable to Blanking-Period Events: A Propensity-Matched Cohort Study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Paroxysmal or persistent atrial fibrillation undergoing first-time catheter radiofrequency ablation (n=365). Intervention: Persistent atrial fibrillation phenotype undergoing first-time catheter radiofrequency ablation vs. Paroxysmal atrial fibrillation phenotype undergoing first-time catheter radiofrequency ablation. Primary outcome: Atrial fibrillation recurrence (documented atrial arrhythmia lasting >=30 seconds after the 3-month blanking period) in the propensity-matched cohort (HR 0.411, 95% CI 0.079–2.140, p=0.291).

Q: What does this research mean for the field?

Apparent differences in recurrence and clinical outcomes between paroxysmal and persistent atrial fibrillation after catheter ablation are driven by events occurring during the 3-month blanking period, with no significant differences observed after their exclusion. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Xiaofei Li¹; Xu Longhua; Na Yao; Jifang Liu; Yuedong Sun¹; Luhua Yin¹

doi:10.21203/rs.3.rs-10964047/v1

October 27, 2026Open Access

Apparent Recurrence Differences between Paroxysmal and Persistent Atrial Fibrillation after Catheter Ablation Are Attributable to Blanking-Period Events: A Propensity-Matched Cohort Study

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Key result

Persistent AF shows no difference in post-ablation recurrence or hospitalization compared with paroxysmal AF.

HR 0.411
95% CI 0.079–2.140
P=0.291
n=365

Why the study?

The independent impact of AF type on long-term prognosis after catheter ablation remains debated.

Does persistent atrial fibrillation compared with paroxysmal atrial fibrillation independently increase the long-term risk of all-cause hospitalization, AF recurrence (after the 3-month blanking period), stroke/bleeding, or heart failure after first-time catheter radiofrequency ablation?

Key Points

Determine whether atrial fibrillation type independently influences long-term clinical outcomes following catheter ablation after adjusting for baseline imbalances and blanking-period events.
Single-center retrospective cohort analyzing 365 patients (239 paroxysmal, 126 persistent) undergoing first-time catheter ablation between 2016 and 2025.
Conducted 1:1 propensity score matching (caliper 0.1, exact on heart failure history) creating 65 matched pairs, followed by pair-clustered Cox models, inverse probability of treatment weighting, and protocol-limited 5-year follow-up.
After excluding 3-month blanking-period recurrences, matched analyses showed no differences in AF recurrence (HR 0.411, 95% CI 0.079–2.140, P = 0.291) or all-cause hospitalization (HR 0.948, 95% CI 0.504–1.784, P = 0.869).
Composite stroke/bleeding (HR 2.162, 95% CI 0.186–25.109, P = 0.538) and heart failure (HR 0.676, 95% CI 0.109–4.173, P = 0.673) showed no significant differences between groups.
Recurrences during the 3-month blanking period occurred in 21 of 50 patients (42%) and were disproportionately frequent in persistent AF (13/22, 59% vs 8/28, 29%); including these events created an artificial two-fold risk elevation (crude HR 1.758, P = 0.049; IPTW HR 2.054–2.223, P < 0.05).

Study Design

Type

Cohort (n=365)

Multicenter

No

Structured PICO

Does persistent atrial fibrillation compared with paroxysmal atrial fibrillation independently increase the long-term risk of all-cause hospitalization, AF recurrence (after the 3-month blanking period), stroke/bleeding, or heart failure after first-time catheter radiofrequency ablation?

P

Population

365 adults (65 propensity-matched pairs) with paroxysmal (n=239) or persistent (n=126) atrial fibrillation undergoing first-time radiofrequency catheter ablation at a single center in China, followed for up to 5 years (median 29 months in paroxysmal and 21 months in persistent AF).

E

Exposure

Persistent atrial fibrillation phenotype undergoing first-time catheter radiofrequency ablation

C

Comparator

Paroxysmal atrial fibrillation phenotype undergoing first-time catheter radiofrequency ablation

O

Outcome

Four co-primary time-to-first-event outcomes over up to 5 years of protocol-limited follow-up: (1) all-cause hospitalization, (2) AF recurrence (documented atrial arrhythmia lasting >=30 seconds after the 3-month blanking period), (3) composite of stroke or clinically significant bleeding, and (4) heart failure (new-onset or worsening HF requiring hospitalization or escalation of HF therapy).hard clinical

Main Result

Hazard Ratio: 0.411 (95% CI 0.079–2.14)

p-value: p=0.291

Limitations

Single-center retrospective design with modest sample size and low event counts in the matched cohort (38 hospitalizations, 7 AF recurrences, 5 HF events, 3 stroke/bleeding events), resulting in severe underpowering.
Exclusion of 21 of 50 recorded recurrences (42%) occurring within the 3-month blanking period substantially reduced the recurrence event count.
Follow-up times were recorded at monthly precision, preventing temporal ordering of same-month recurrence and clinical events.
AF recurrence relied on symptom- and ECG-based detection rather than continuous monitoring, potentially underestimating asymptomatic recurrences.
Shorter follow-up duration in the persistent AF group (median 21 vs 29 months in the full cohort) and residual baseline imbalances after matching and IPTW.
Single-center retrospective design with modest sample size and severely underpowered event counts in the matched cohort (38 hospitalizations, 7 recurrences, 5 HF events, 3 stroke/bleeding events)
Monthly precision of event times prevented temporal ordering of same-month AF recurrence and hospitalizations
AF recurrence detection relied on symptoms and ECGs, which may underestimate asymptomatic recurrences
Residual covariate imbalance persisted after matching (12 of 24 covariates with SMD > 0.1) and IPTW
Shorter follow-up duration in the persistent AF group (median 21 vs 29 months in the full cohort) due to later enrollment, and lack of detailed ablation lesion set data

Implication

Apparent two-fold higher post-ablation recurrence rates in persistent versus paroxysmal AF were entirely driven by early recurrences within the 3-month blanking period (59% vs 29% of recurrences), with no differences in late recurrence or clinical outcomes after blanking-period exclusion and propensity adjustment.

Abstract

Background Whether atrial fibrillation (AF) type independently determines long-term prognosis after catheter ablation remains debated. We compared outcomes between paroxysmal and persistent AF after ablation using propensity score matching (PSM) with inverse probability of treatment weighting (IPTW). Methods This single-center retrospective cohort included 365 patients (239 paroxysmal, 126 persistent) undergoing first-time ablation (2016–2025). Outcomes were all-cause hospitalization, AF recurrence, a composite stroke/bleeding outcome, and heart failure (HF). PSM (1:1, exact on HF history, caliper 0.1) yielded 65 matched pairs; analyses comprised pair-clustered Cox models, restricted mean survival time, IPTW, multivariable adjustment, FDR-corrected subgroups, and LASSO-Cox. Follow-up was protocol-limited to 5 years; no deaths occurred. Results Recurrences within the 3-month blanking period were excluded: 21 of 50 (42%), disproportionately frequent in persistent AF (13/22, 59% vs 8/28, 29%). No outcome differed between groups after matching (hospitalization HR 0.948, 95% CI 0.504–1.784; recurrence 0.411, 0.079–2.140; stroke/bleeding 2.162, 0.186–25.109; HF 0.676, 0.109–4.173). Including blanking-period events produced an apparent two-fold higher recurrence risk in persistent AF (crude HR 1.758, P = 0.049; IPTW HR 2.054–2.223, P < 0.05) that disappeared after exclusion (crude HR 1.020, P = 0.961; IPTW HR 1.147–1.215, P > 0.6). Subgroup findings were exploratory and did not survive FDR correction. Conclusions After applying the consensus blanking-period definition, paroxysmal and persistent AF showed no differences in hospitalization, recurrence, stroke/bleeding, or HF across all analytic approaches; apparent recurrence differences were entirely attributable to blanking-period events, disproportionately frequent in persistent AF. Findings are limited by small event counts and month-level follow-up precision.

Discussion

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Cite This Study

Li¹ et al. (2026) conducted a cohort in Paroxysmal or persistent atrial fibrillation undergoing first-time catheter radiofrequency ablation (n=365). Persistent atrial fibrillation phenotype undergoing first-time catheter radiofrequency ablation vs. Paroxysmal atrial fibrillation phenotype undergoing first-time catheter radiofrequency ablation was evaluated on Atrial fibrillation recurrence (documented atrial arrhythmia lasting >=30 seconds after the 3-month blanking period) in the propensity-matched cohort (HR 0.411, 95% CI 0.079–2.140, p=0.291). Persistent vs paroxysmal AF showed no difference in post-ablation recurrence after blanking-period exclusion (matched HR 0.411, 95% CI 0.079-2.140) or hospitalization (HR 0.948).

synapsesocial.com/papers/6ae215a76deabab0889e2cbe https://doi.org/10.21203/rs.3.rs-10964047/v1

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Apparent Recurrence Differences between Paroxysmal and Persistent Atrial Fibrillation after Catheter Ablation Are Attributable to Blanking-Period Events: A Propensity-Matched Cohort Study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Apparent Recurrence Differences between Paroxysmal and Persistent Atrial Fibrillation after Catheter Ablation Are Attributable to Blanking-Period Events: A Propensity-Matched Cohort Study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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