Freedom of Atrial Fibrillation Predictions After Pulmonary Vein Isolation: A Review of Current Evidence

Abstract

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, poses significant challenges due to high morbidity, mortality, and healthcare costs. Pulmonary vein isolation (PVI) is a cornerstone treatment that disrupts arrhythmogenic pathways through electrically isolating pulmonary veins. However, recurrence rates remain substantial, driven by complex demographic, biochemical, imaging, and electrocardiographic factors reflecting underlying pathophysiologies. Advancements in PVI techniques, including pulsed-field ablation and electroanatomic mapping, have improved procedural success. Antiarrhythmic drugs (AADs) enhance outcomes by stabilising atrial activity and reducing early recurrence, although the long-term benefits of these drugs are debated. Nonetheless, integrating these predictors into patient selection, procedural strategies, and post-ablation management enables personalised interventions. This review uniquely integrates demographic, biochemical, imaging, electrocardiographic, and procedural predictors into a multidimensional framework for comprehensive risk stratification of PVI outcomes. We critically evaluate emerging procedural techniques, notably pulsed-field ablation (PFA), emphasising the clinical applicability of these procedures. Key biochemical markers (e.g., N-terminal pro-brain natriuretic peptide (NT-pro-BNP), C-reactive protein (CRP), interleukin-6 (IL-6)) and imaging findings (e.g., left atrial fibrosis, epicardial fat) reflecting atrial pathophysiology are discussed in detail. Furthermore, readily accessible electrocardiographic parameters such as prolonged P wave duration and dispersion are emphasised as practical tools for patient risk assessment. This multidimensional approach holds promise for reducing AF recurrence and improving long-term outcomes in PVI, advancing patient-centered care in AF management.

Keywords: atrial fibrillation; direct current cardioversion; electrocardiogram; outcomes.

Fig. 1.

Different modalities of pulmonary vein isolation for atrial fibrillation. (1A) Pulsed-field ablation. (2A) Cryoballoon ablation. (3A) Very high-powered short-duration ablation. (4A) Radiofrequency ablation.

Fig. 2.

Stepwise approach for diagnosing and treating atrial fibrillation. AF, atrial fibrillation; ECG, electrocardiogram.