Real-world evaluation of atrial fibrillation burden and recurrence after ablation using ambulatory cardiac monitoring
J M Ashburner, S Schmitt, V Fokin, A J Battisti, M TurakhiaAbstract
Background
Catheter ablation is an effective rhythm-control strategy for atrial fibrillation (AF) but has significant rates of recurrence. The OCEAN trial recently demonstrated safety of discontinuation of anticoagulation for patients without AF recurrence ≥30 sec, though contemporary guidelines emphasize AF burden rather than recurrence alone as a clinically meaningful measure in post-ablation patients. Ambulatory cardiac monitoring (ACM) enables measurement of AF recurrence timing and burden, and identification of other arrhythmias post-ablation. The ACM evaluated in this study was independently validated to have a correlation of 0.99 with an atrial pacemaker lead in AF burden determination. Data linking real-world ACM results in AF patients post-ablation is limited.
Purpose
To evaluate AF recurrence, burden, and detection of other clinically relevant arrhythmias in patients undergoing ACM following AF ablation.
Methods
We retrospectively analyzed 2018-2022 data from US patients ≥18 years monitored ≤14 days with patched-based, continuous ACM within 1-year following AF ablation using commercial fee-for-service and Medicare Advantage claims linked to corresponding clinical monitoring records. AF was classified using ICD-10 codes associated with the ablation procedure as paroxysmal, persistent/permanent, or unspecified. Outcomes included AF recurrence, AF burden, and detection of other arrhythmias.
Results
Among 11,051 patients, 53% had paroxysmal, 36% persistent/permanent, and 11% unspecified AF. Mean (SD) CHA2DS2-VASc was 2.4 (1.5). Median time from ablation to ACM was 113 days and ranged from 110-120 days across AF types. Overall, 21.4% had recurrent AF ≥30 seconds (lowest for paroxysmal [19.2%] vs. persistent/permanent [24.4%] and unspecified [22.6%]; both p<0.01). Among all post-ablation patients, 78.6% had 0% burden. Among those with burden >0%, median burden was 11.9% (Q1-Q3: 2.0-89.8%), and was markedly lower for paroxysmal (4.4%; Q1-Q3: 1.1-23.2%) compared to permanent/persistent (43.1%; Q1-Q3: 5.1-100%) and unspecified AF (16.8%; Q1-Q3: 2.1-100%). ACM also identified actionable arrhythmias in 44% of patients, including pauses, ventricular tachycardia, AV block, and sustained supraventricular tachycardia in addition to AF (Table).
Conclusions
In a large real-world cohort of post AF ablation patients monitored with patch-based ambulatory ECG, the proportion free of AF was consistent with prior AF ablation studies. Among those with recurrence, AF burden was substantial and varied by AF severity. The significant rate of sustained SVT suggests residual or new atrial arrhythmogenic activity. These results highlight a sizable population potentially eligible for anticoagulation discontinuation after negative repeat monitoring, based findings from the recent OCEAN trial. For patients with recurrent AF, quantifying burden via 14-day ACM may improve risk stratification and inform individualized management decisions.