Prediction of sinus rhythm maintenance using clinical parameters following atrial fibrillation ablation with pulsed-field and radiofrequency energy

Introduction

While pulsed-field ablation (PFA) and radiofrequency ablation (RFA) are both effective techniques for atrial fibrillation (AF) treatment, predictors of long-term sinus rhythm (SR) maintenance after these procedures remain under investigation. We aimed to identify clinical predictors of 12-month SR maintenance in a cohort of patients undergoing AF ablation using PFA or RFA.

Methods

In this prospective cohort of 386 patients undergoing AF ablation (260 PFA, 126 RFA) between January 2023 to December 2024, we performed logistic regression to evaluate the association between baseline clinical parameters and 12-month SR maintenance. Follow-up was performed on outpatient basis with a minimum of one 24-h Holter recording during the first 6 months, one 24-h Holter recording at 12 months and 2 outpatient controls.

Predictors included those identified as statistically significant in univariate analysis: age, sex, weight, BMI, ischemic heart disease, arterial hypertension, left ventricular ejection fraction (EF), left atrial size (LS diameter), AF type (paroxysmal vs. persistent), diabetes, and ablation type (PFA vs. RFA). Models were constructed separately for the entire cohort and for PFA and RFA subgroups.

Results

In the full cohort (n = 386), higher age (OR 0.96; 0.93–0.99; p = 0.007), higher weight (OR 0.97;0.96–0.99; p = 0.003), presence of ischemic heart disease (OR 0.51; 0.22–1.21; p = 0.12) and persistent AF (OR 0.50; 0.27–0.92; p = 0.03) were associated with lower likelihood of maintaining SR. The multivariate model achieved an AUC of 0.73.

In the PFA subgroup, also higher age (OR 0.92; 0.87–0.96; p < 0.001), higher weight (OR 0.96; 0.93–0.98; p < 0.001) were associated with reduced SR maintenance. This model achieved an AUC of 0.79.

In the RFA subgroup, predictors included persistent AF (OR 0.41; 0.17–0.95; p = 0.04) and baseline beta-blocker use (OR 2.98;1.20–7.47; p = 0.02), with an AUC of 0.69.

Conclusion

Age, weight, AF type, and selected structural heart disease parameters are key clinical predictors of AF recurrence following catheter ablation irrespective of the used technology. However, predictive performance was substantially stronger in patients treated with PFA compared to RFA, suggesting the need for modality-specific risk stratification. Incorporating these factors into pre-procedural decision-making may improve patient selection and long-term outcomes.ROC curves