Variation and clinical consequences of wait-times for atrial fibrillation ablation: population level study in Ontario, Canada

Abstract

Aims: Atrial fibrillation (AF) is the most common cardiac rhythm disorder. Emerging evidence supporting the efficacy of catheter ablation in managing AF has led to increased demand for this therapy, potentially outpacing the capacity to perform this procedure. Mismatch between demand and capacity for AF ablation results in wait-times which have not been comprehensively evaluated at a population level. Additionally, the consequences of such delays in AF ablation, namely the risk of hospitalization or adverse events, have not been studied.

Methods and results: This observational cohort study included adults referred for catheter ablation to treat AF in Ontario, Canada, between 1 April 2016 and 31 March 2020. Wait-time was defined from referral to the earliest of ablation, death, off-list, or the study endpoint of 31 March 2022. The outcomes of interest included a composite of death, hospitalization for AF/heart failure, and emergency department visit for AF/heart failure. Our study cohort included 6253 patients referred for de novo AF ablation. The median wait-time for patients who received and who did not receive ablation was 218 days (IQR: 112-363) and 520 days (IQR: 270-763), respectively. Wait-time increased consistently for patients referred between October 2017 and March 2020. Mortality was rare, but significant morbidity was observed, affecting 19.2% of patients on the waitlist for AF ablation. Paroxysmal AF was associated with a statistically significant greater risk for adverse outcomes on the waitlist (HR 1.51, 95% CI 1.18-1.93).

Conclusion: Wait-times for AF ablation are increasing and are associated with significant morbidity.

Keywords: Atrial fibrillation; Catheter ablation; Wait-times.

Graphical abstract

Figure 1

Study population flow diagram for all patients referred for catheter ablation to treat atrial fibrillation between 1 April 2016 and 31 March 2020.

Figure 2

Temporal trends in the number of referrals and ablations presented by referral month.

Figure 3

Wait-time in days from referral to off-list, death, ablation, or study endpoint of 31 March 2022 (A) and presented separately by ablation status (B). Among patients who did not receive ablation, median wait-time from referral to off-list, death, or study endpoint was 520 (IQR: 270–763) days, while the median referral to ablation time was 218 (IQR: 112–363) days. IQR, interquartile range.

Figure 4

Median wait-time from referral to the earliest of ablation, death, off-list, or study endpoint on 31 March 2022 presented by referral month.

Figure 5

Cumulative incidence function for composite outcome of death, hospitalization for AF/HF, or ED visit for AF/HF. AF, atrial fibrillation; ED, emergency department; HF, heart failure.

Figure 6

Cause-specific proportional hazards model of risk factors for the composite endpoint of death, hospitalization for AF/HF, or ED visit for AF/HF. AF, atrial fibrillation; CI, confidence interval; ED, emergency department; HF, heart failure. Supplementary material online, Figure S1. Demographic indicators from the Ontario Marginalization Index are presented by type of AF.