Incidence and predictors of atrial fibrillation recurrence after percutaneous ablation in the elderly population: insights from a single-center registry

Background

Atrial fibrillation (AF) in the elderly involves a complex interplay between multiple age-related factors. While the benefit of percutaneous ablation is proven in previous studies, elderly patients are still underrepresented [1], with evidence of more procedural complications [2], and a few data on late recurrence. Studying the predictors of recurrence in this specific age group could help guide patient selection and improve long-term procedural outcomes.

Purpose

To identify the incidence and predictors of AF recurrence after AF ablation in the elderly over longer-term follow-up.

Methods

This observational retrospective study included all consecutive patients undergoing percutaneous AF ablation at a tertiary university hospital between January 2018 and December 2023, with a follow-up duration extending up to 7 years post-ablation. Patients aged 75 years or older (Elderly group) were compared to those aged <75 years (Non-elderly group). The primary endpoint was AF recurrence at follow-up. Multivariate Cox regression analysis was performed to explore independent predictors of AF recurrence.

Results

A total of 1,155 AF ablation cases were included. There were 153 patients in the elderly group and 1,002 in the non-elderly group; median [IQR] follow-up duration was 3.3 [1.8–5.0] years. The elderly population were more likely to be females (59.5% vs 33.1%, p<0.001), with higher prevalence of hypertension (59.2% vs 40.1%, p<0.001), and lower obesity (body mass index >30 Kg/m2, 32.8% vs 46.3%, p=0.005). Elderly patients were more symptomatic at presentation, with functional NYHA class II-III (67.8% vs 56.9%, p=0.01), had greater moderate-to-severe left atrial (LA) dilatation (45.1% vs 26.7%, p<0.001) and more moderate-to-severe mitral regurgitation (8.5% vs 2.3%, p<0.001); there were no differences in the prevalence of persistent AF (49% vs 45.1%, p=0.38), or left ventricular systolic dysfunction (LVSD) (17% vs 19.3%, p =0.58).

The rate of AF recurrence was similar between both groups in the first two years (20.3% vs 21.7%, p=0.75 for the first year, 32% vs 31.5%, p=0.93 for the second year). However, after 5 years, the recurrence rate was significantly higher in the elderly group (6.5% vs 1.4%, p<0.001). Within the elderly group, female gender (HR:3.33; 95%CI: 1.61-6.87, p=0.001), obesity (HR:2.24; 95%CI: 1.20-4.18, p=0.01), obstructive sleep apnea (OSA) (HR:5.34; 95%CI: 1.47-19.47, p=0.01), and moderate-to-severe LVSD (HR:3.09; 95%CI: 1.31-7.29, p=0.01) were independent predictors of recurrence. In contrast, persistent AF, moderate-to-severe LA dilatation, and moderate-to-severe LVSD were predictors of AF recurrence in the non-elderly group.

Conclusion

AF recurrence in elderly patients after percutaneous AF ablation is comparable to non-elderly patients, with higher long-term recurrence beyond 5 years. In elderly patients, female gender, obesity, and OSA may be more powerful predictors of post-ablation AF recurrence.Kaplan-Meier curve for AF recurrenceMV analysis-predictors of AF recurrence