The APPLE Score - A Novel Score for the Prediction of Rhythm Outcomes after Repeat Catheter Ablation of Atrial Fibrillation

Abstract

Background: Arrhythmia recurrences after catheter ablation occur in up to 50% within one year but their prediction remains challenging. Recently, we developed a novel score for the prediction of rhythm outcomes after single AF ablation demonstrating superiority to other scores. The current study was performed to 1) prove the predictive value of the APPLE score in patients undergoing repeat AF ablation and 2) compare it with the CHADS2 and CHA2DS2-VASc scores.

Methods: Rhythm outcome between 3-12 months after AF ablation were documented. The APPLE score (one point for Age >65 years, Persistent AF, imPaired eGFR (<60 ml/min/1.73m2), LA diameter ≥43 mm, EF <50%) was calculated in every patient before procedure.

Results: 379 consecutive patients from The Leipzig Heart Center AF Ablation Registry (60±10 years, 65% male, 70% paroxysmal AF) undergoing repeat AF catheter ablation were included. Arrhythmia recurrences were observed in 133 patients (35%). While the CHADS2 (AUC 0.577, p = 0.037) and CHA2DS2-VASc scores (AUC 0.590, p = 0.015) demonstrated low predictive value, the APPLE score showed better prediction of arrhythmia recurrences (AUC 0.617, p = 0.002) than other scores (both p<0.001). Compared to patients with an APPLE score of 0, the risk (OR) for arrhythmia recurrences was 2.9, 3.0 and 6.0 (all p<0.01) for APPLE scores 1, 2, or ≥3, respectively.

Conclusions: The novel APPLE score is superior to the CHADS2 and CHA2DS2-VASc scores for prediction of rhythm outcomes after repeat AF catheter ablation. It may be helpful to identify patients with low, intermediate or high risk for recurrences after repeat procedure.

Fig 1. Prediction of arrhythmia recurrences using CHADS_2, CHA₂DS₂-VASc, and APPLE scores.

Fig 2. APPLE score and risk for arrythmia recurrences in repeat catheter ablation in whole study population (n = 379).

The figure presents incidence of arrhythmia recurrences (%) according to each APPLE score point. Compared to patients with an APPLE score of 0 (reference), the risk (OR) for arrhythmia recurrences was 2.9 (95% CI 1.4–6.3, p = 0.006), 3.0 (95% CI 1.3–6.6, p = 0.007) and 6.0 (95% CI 2.2–16.8, p = 0.001) for APPLE scores 1, 2, or ≥3, respectively.