Patterns of Postablation Recurrence and Adverse Cardiovascular Outcomes in Patients With Atrial Fibrillation

Abstract

Background: Atrial arrhythmia recurrence after atrial fibrillation (AF) catheter ablation is conventionally assessed as a binary end point. However, the prognostic value of recurrence patterns is less studied.

Methods and results: This study included patients undergoing catheter ablation from the multicenter China Atrial Fibrillation Registry study (2011-2022). Postablation AF patterns within 1 year were categorized as nonrecurrence, paroxysmal AF recurrence, or persistent AF (PersAF) recurrence. Cardiovascular outcomes included cardiovascular death, thromboembolism, and cardiovascular hospitalization. Cox proportional models with landmark analysis were used to assess the relationship between recurrence patterns and outcomes. Sensitivity analyses were conducted using Fine-Gray models, considering death unrelated to the outcomes as the competing risk and evaluating 2-year recurrence patterns. Among 13 811 patients (mean age, 60.5±10.8 years; 66.1% men), those with preablation PersAF, prior stroke/transient ischemic attack/systemic embolism, and increased left atrial diameter were more likely to develop PersAF postablation. Compared with nonrecurrence, PersAF recurrence was associated with higher risks of cardiovascular death (hazard ratio [HR], 2.03 [95% CI, 1.20-3.43]; P=0.009), thromboembolism (HR, 1.50 [95% CI, 1.09-2.06]; P=0.012), and cardiovascular hospitalization (HR, 1.74 [95% CI, 1.56-1.94]; P<0.001) during a median follow-up of 3.02 years (interquartile range, 1.44-5.03 years), while paroxysmal AF recurrence was only significantly associated with an increased risk of cardiovascular hospitalization (HR, 1.98 [95% CI, 1.83-2.14], P<0.001). Sensitivity analyses yielded consistent results.

Conclusions: Postablation PersAF recurrence was associated with significantly higher risks of cardiovascular death and thromboembolism, compared with paroxysmal AF recurrence and nonrecurrence, indicating the prognostic importance of recurrence patterns.

Registration: URL: www.chictr.org.cn/; unique identifier: ChiCTR-OCH-13003729.

Keywords: atrial fibrillation; cardiovascular death; catheter ablation; patterns of recurrence; thromboembolism.

Figure 1. Associations between AF recurrence patterns and cardiovascular outcomes.

*Adjusted for age, sex, body mass index, preablation AF pattern, history of heart failure, hypertension, diabetes, stroke/transient ischemic attack/systemic embolism, coronary artery disease, and oral anticoagulation status at 12 months. AF indicates atrial fibrillation; HR, hazard ratio; PAF, paroxysmal atrial fibrillation; and PersAF, persistent atrial fibrillation.

Figure 2. Proportions of postablation recurrence patterns among patients with paroxysmal or persistent atrial fibrillation before ablation.

PAF indicates paroxysmal atrial fibrillation; and PersAF, persistent atrial fibrillation.

Figure 3. Association between AF recurrence patterns and cardiovascular outcomes stratified by preablation AF patterns.

Among 8778 patients with preablation PAF, 6566 were categorized as nonrecurrence, 1890 as PAF recurrence, and 322 as PersAF recurrence. Among 5033 patients with preablation PersAF, 3551 were categorized as nonrecurrence, 521 as PAF recurrence, and 961 as PersAF recurrence. *Adjusted for age, sex, body mass index, history of heart failure, hypertension, diabetes, stroke/transient ischemic attack/systemic embolism, coronary artery disease, and oral anticoagulantion status at 12 months. AF indicates atrial fibrillation; HR, hazard ratio; PAF, paroxysmal atrial fibrillation; and PersAF, persistent atrial fibrillation.