Background and Objective:
Although catheter ablation has emerged as a very effective therapeutic option for atrial fibrillation (AF), achieving a durable rhythm control, especially in persistent and long-standing persistent AF, remains challenging. In this single-center retrospective analysis, we evaluate the long-term outcomes of catheter ablation in patients with persistent AF over an extended follow-up period and discuss possible predictors of AF recurrence.
Methods and Results:
A total of 282 patients who underwent catheter ablation for persistent and long-standing persistent AF between 2009 and 2021 at our center were included. We retrospectively collected and analysed their clinical characteristics, procedural and follow-up data over a period extending up to 17 years. Long-term procedure success was defined as freedom from symptomatic atrial arrhythmias without adjunctive use of antiarrhythmic drugs (AAD).
The mean age was 60.6 ± 9.9 years and 78 % were male. The mean follow-up duration was 62.4 ± 38.9 months (min. to max., 11 to 212 months). Pulmonary vein isolation with cryoballoon was the most performed index ablation technique (49.3%), followed by point-to-point radiofrequency ablation (25.9%) and multielectrode pulmonary vein ablation catheter (PVAC) (24.8%).
A total of 214 patients (75.9%) underwent at least a second ablation procedure, with a median time to first re-ablation of 16 months (IQR: 8–33 months). Younger age (OR 0.95, p=0.004) and greater number of prior antiarrhythmic drugs (OR 1.70, p=0.009) were identified as independent predictors of the necessity of a second ablation procedure.
Long-term success was observed in 18.4% of all patients (n= 52). However, only 36.5 % (n=19) of these individuals required no re-ablation. Multivariate logistic regression identified age (OR 1.04, 95% CI 1.01–1.07, p=0.023), body mass index (BMI) (OR 1.13, 95% CI 1.03–1.24, p=0.009) and ejection fraction (OR 1.04, 95% CI 1.01–1.07, p=0.017) as independent predictors of AF recurrence.
The overall procedural complication rate was 4 % (n=23) for all evaluated ablations, with inguinal vascular complications being the most frequent (1.5%, n=9). Seven patients (2.5%) died during the follow-up period at a mean age of 69.4 ± 8.3 years.
Conclusions:
The observed high rate of re-ablations and low rate of freedom from AF without adjunctive AAD use in this cohort with a very long follow-up underline the complexity of managing this group of AF patients and the need for an individually tailored approach. A hybrid strategy combining catheter ablation with antiarrhythmic drug treatment may enhance the maintenance of sinus rhythm.
