Timing of atrial fibrillation recurrence after ablation: real-world results with extended ambulatory cardiac monitoring
A J Battisti, S Schmitt, V Fokin, J M Ashburner, M TurakhiaAbstract
Background
Catheter ablation is an established rhythm-control strategy for atrial fibrillation (AF), yet recurrence is common and may occur at varying times post-procedure. Routine post-ablation assessment with 12-lead ECG or 24-48 hour Holter monitoring may have limited sensitivity for detecting AF recurrence. Extended ambulatory cardiac monitoring (ACM) of ≤14 days enables continuous assessment of AF recurrence and burden. Real-world data on timing of AF recurrence in patients undergoing ACM post-ablation are limited.
Purpose
To evaluate the timing of AF recurrence and repeat ablation rates in patients undergoing ACM following AF ablation.
Methods
We retrospectively analyzed 2018–2022 U.S. adults (≥18 years) who underwent AF ablation and received ≤14 days of continuous patch-based ACM within one-year. Commercial and Medicare Advantage claims were linked to ACM records. AF type was classified using ICD-10 codes associated with the ablation procedure as paroxysmal, persistent/permanent, or unspecified. AF recurrence was defined as any episode ≥30 seconds. Time to first AF detection was categorized as 0-2 days, >2-7 days, and >7 days after monitor activation to assess incremental yield of extended monitoring. Repeat ablations within one-year were limited to procedures in 2018-2021 to ensure follow-up.
Results
The analysis included 11,051 patients. AF type at time of ablation was paroxysmal in 53%, persistent/permanent 36%, and unspecified 11%. Mean (SD) CHA2DS2-VASc score was 2.4 (1.5). Median time from ablation to ACM was 113 days (range 110–120 days across AF types). During monitoring, 21.4% had recurrent AF ≥30 seconds, with recurrence lowest in paroxysmal (19.2%) and highest in persistent/permanent (24.4%, p<0.001). Among those with recurrence, time to detection varied. More than one-quarter (26.1%; 619/2,368) of patients with recurrent AF were first detected after ≥48 hours of monitoring (highest for paroxysmal [29.8%] vs. permanent/persistent [22.3%] and unspecified AF [24.9%]). Recurrent AF was detected after day 2 through day 7 in 17.8% of cases (paroxysmal [20.3%], permanent/persistent [15.2%], unspecified [17.0%]) and after day 7 in 8.3% (paroxysmal [9.5%], permanent/persistent [7.1%], unspecified [7.9%]. Within one-year, 8.0% underwent repeat ablation (paroxysmal: 7.2%; persistent/permanent: 8.8%; unspecified: 9.1%; Table).
Conclusions
Extended-duration ACM identified a substantial proportion of post-ablation patients with AF recurrence that would have been missed by 48-hour monitoring. Detection patterns varied by AF type, with late recurrences particularly common among patients with paroxysmal AF. These findings underscore the importance of prolonged post-ablation monitoring to more accurately assess rhythm outcomes, identify patients at risk for repeat ablation, and to inform management decisions, including consideration of anticoagulation discontinuation based on AF recurrence or burden.