January 1, 2016Open Access

Radiofrequency Ablation of Persistent Atrial Fibrillation

Key Result

Longer diagnosis-to-ablation time in persistent atrial fibrillation patients was associated with higher recurrence rates, with a hazard ratio of 2.44 for the highest quartile.

Structured PICO

Does a shorter diagnosis-to-ablation time improve freedom from arrhythmia recurrence in patients undergoing first-time radiofrequency ablation for persistent atrial fibrillation?

Population

1,241 consecutive patients undergoing first-time radiofrequency ablation for recurrent symptomatic persistent atrial fibrillation (PersAF) failing at least one antiarrhythmic medication. Mean age 61.0, 78.5% male. Excluded: paroxysmal AF, prior AF ablation, prior cardiac surgery, and patients in whom the time of first PersAF diagnosis could not be determined.

Intervention

Radiofrequency catheter ablation (pulmonary vein isolation, with additional superior vena cava isolation and left atrial ablations at operator discretion) performed at longer time intervals from first PersAF diagnosis (assessed in quartiles: 1.1-3.0 years, 3.1-6.5 years, and >6.5 years).

Comparator

Radiofrequency catheter ablation performed at shorter time intervals from first PersAF diagnosis (first quartile: ≤1 year).

Outcome

Freedom from atrial arrhythmia recurrence (AF, atrial flutter, or atrial tachycardia lasting ≥30 seconds) over 2 years of follow-up after a single ablation procedure and off antiarrhythmic medications.composite

Shorter time intervals between the first diagnosis of persistent atrial fibrillation and catheter ablation are strongly associated with better procedural outcomes and lower rates of arrhythmia recurrence.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Background— Various ablation strategies of persistent atrial fibrillation (PersAF) have had disappointing outcomes, despite concerted clinical and research efforts, which could reflect progressive atrial fibrillation–related atrial remodeling. Methods and Results— Two-year outcomes were assessed in 1241 consecutive patients undergoing first-time ablation of PersAF (2005–2012). The time intervals between the first diagnosis of PersAF and the ablation procedures were determined. Patients had echocardiograms and measures of B-type natriuretic peptide and C-reactive protein before the procedures. The median diagnosis-to-ablation time was 3 years (25th–75th percentiles 1–6.5). With longer diagnosis-to-ablation time (based on quartiles), there was a significant increase in recurrence rates in addition to an increase in B-type natriuretic peptide levels ( P =0.01), C-reactive protein levels ( P <0.0001), and left atrial size ( P =0.03). The arrhythmia recurrence rates over 2 years were 33.6%, 52.6%, 57.1%, and 54.6% in the first, second, third, and fourth quartiles, respectively ( P categorical <0.0001). In Cox Proportional Hazard analyses, B-type natriuretic peptide levels, C-reactive protein levels, and left atrial size were associated with arrhythmia recurrence. The diagnosis-to-ablation time had the strongest association with the ablation outcomes which persisted in multivariable Cox analyzes (hazard ratio for recurrence per +1Log diagnosis-to-ablation time 1.27, 95% confidence interval 1.14–1.43; P <0.0001; hazard ratio fourth versus first quartile 2.44, 95% confidence interval 1.68–3.65; P categorical <0.0001). Conclusions— In patients with PersAF undergoing ablation, the time interval between the first diagnosis of PersAF and the catheter ablation procedure had a strong association with the ablation outcomes, such as shorter diagnosis-to-ablation times were associated with better outcomes and in direct association with markers of atrial remodeling.

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