Which are the most reliable predictors of recurrence of atrial fibrillation after transcatheter ablation?: a meta-analysis

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Abstract

Context

Transcatheter ablation of atrial fibrillation (AF) has undergone important development, with acceptable midterm results in terms of the safety and recurrence. A meta-analysis was performed to identify the periprocedural complications, midterm success rates and predictors of recurrence after AF ablation.

Methods and results

4357 patients with paroxysmal AF, 1083 with persistent AF and 1777 with long standing AF were included.

The pooled analysis showed that there was an in-hospital complication rate of tamponade requiring drainage of 0.99% (0.44–1.54; CI 99%), stroke with neurological persistent impairment of 0.22% (0.04–0.47; CI 99%), and stroke without of 0.36% (0.03–0.70; CI 99%) After a follow up of 22 (13–28) months and 1.23 (1.19–1.5; CI 99%) procedures per patient, the AF recurrence rate was 31.20% (24.87–34.81; CI 99%). The persistent AF patients exhibited a greater risk of recurrence after the first ablation (OR 1.78 [1.14, 2.77] CI 99%), but a trend towards non significance was present in the patients with more than one procedure (OR 1.69 [0.95, 3.00] CI 99%). The most powerful predictors of an AF ablation failure in the overall population were a recurrence within 30-days (OR 4.30; 2.00–10.80), valvular AF (OR 5.20; 2.22–9.50) and a left atrium diameter of more than 50 mm (OR 5.10 2.00–12.90; all CI 95%).

Conclusions

Persistent AF remains burdened from higher recurrence rates, however not so following redo-procedures. Three predictors, valvular AF, a left atrium diameter longer than 50 mm and recurrence within 30 days, could be appraised to drive selection of patients and therapeutic strategy.

Introduction

Transcatheter atrial fibrillation (AF) ablation (TCAFA) is usually undertaken in patients with symptomatic episodes of AF resistant to at least one anti-arrhythmic drug. Multiple single center randomized studies and multicenter prospective registries comparing anti-arrhythmic drug therapy with TCAFA have shown significantly higher rates of patients in sinus rhythm after an invasive strategy at one year of follow up [1], [2], [3], [4], [5], [6].

Many observational studies have reported predictors identified by multivariate analyses including the time spent in persistent AF, structural heart disease, left ventricular impairment, and, perhaps most consistently, the left atrial diameter [7]; in the case in which they were confirmed in larger datasets these clinical features could be very useful for cardiologists and general clinicians both for a correct selection of patients deferred to an invasive strategy and to accurately manage the following procedure. However, to the best of our knowledge, no meta-analyses have been performed to appraise the results of real life observational studies of AF ablation, and their complication rates and the most powerful predictors of recurrence.

Section snippets

Methods

The present research was elaborated according to current guidelines, including the recent Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) amendment to the Quality of Reporting of Meta-analyses (QUOROM) statement, and recommendations from the Cochrane Collaboration and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) [8], [9], [10], [11].

Results

From the 3475 citations first screened, 27 complete reports were evaluated for inclusion in the present research and finally 19 studies were included in the review [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33] (Fig. 1). One study was excluded because it included patients with hypertrophic cardiomyopathy [35], one because it appraised robotic navigation [34], 4 for duplicate reporting [36], [37], [38], [39], and one because

Discussion

The main results of the present work were: a) AF ablation procedures remain burdened with in-hospital complications, although infrequent in experienced centers, b) TCAFA ablation obtains satisfactory midterm success rates, c) the success following redo procedures did not differ between paroxysmal and persistent AF, and d) valvular AF, a left atrium diameter of more than 50 mm and recurrence within 30 days, could help to better tailor the clinical and interventional strategies.

The overall

Acknowledgment

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

Dr. D'Ascenzo conceived the project, and performed the literature search with Dr. Corleto and the analysis with Dr. Biondi-Zoccai. Prof. Gaita, Dr. Anselmino, Dr. Ferraris, Dr. di Biase, Dr. A. Natale, Dr. Hunter, Dr. Schilling, Dr. Miyazaki, Dr. Tada, Dr. Aonuma, Dr. Yenn-Jiang, Dr. Tao, Dr. Ma, Dr. Packer and Dr. Hammill participated in

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