Five-year follow-up after catheter ablation of persistent atrial fibrillation using the stepwise approach and prognostic factors for success.
BACKGROUND
In the meantime, catheter ablation is widely used for the treatment of persistent atrial fibrillation (AF). There is a paucity of data about long-term outcomes. This study evaluates (1) 5-year single and multiple procedure success and (2) prognostic factors for arrhythmia recurrences after catheter ablation of persistent AF using the stepwise approach aiming at AF termination.


RESULTS
A total of 549 patients with persistent AF underwent de novo catheter ablation using the stepwise approach (2007-2009). A total of 493 patients were included (Holter ECGs ≥ every 6 months). Mean follow-up was 59 ± 16 months with 2.1 ± 1.1 procedures per patient. Single and multiple procedure success rates were 20.1% and 55.9%, respectively (80% off antiarrhythmic drug). Antiarrhythmic drug-free multiple procedure success was 46%. Long-term recurrences (n=171) were paroxysmal AF in 48 patients (28%) and persistent AF/atrial tachycardia in 123 patients (72%). Multivariable recurrent event analysis revealed the following factors favoring arrhythmia recurrence: failure to terminate AF during index procedure (hazard ratio [HR], 1.279; 95% confidence interval [CI], 1.093-1.497; P = 0.002), number of procedures (HR, 1.154; 95% CI, 1.051-1.267; P = 0.003), female sex (HR, 1.263; 95% CI, 1.027-1.553; P = 0.027), and the presence of structural heart disease (HR, 1.236; 95% CI, 1.003-1.524; P = 0.047). AF termination was correlated with a higher rate of consecutive procedures because of atrial tachycardia recurrences (P = 0.003; HR, 1.71; 95% CI, 1.20-2.43).


CONCLUSIONS
Catheter ablation of persistent AF using the stepwise approach provides limited long-term freedom of arrhythmias often requiring multiple procedures. AF termination, the number of procedures, sex, and the presence of structural heart disease correlate with outcome success. AF termination is associated with consecutive atrial tachycardia procedures.
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.). d.schreiber@uke.de.
Doreen
D
Schreiber
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.).
Thomas
T
Rostock
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.).
Max
M
Fröhlich
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.).
Arian
A
Sultan
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.).
Helge
H
Servatius
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.).
Boris A
BA
Hoffmann
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.).
Jakob
J
Lüker
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.).
Imke
I
Berner
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.).
Benjamin
B
Schäffer
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.).
Karl
K
Wegscheider
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.).
Susanne
S
Lezius
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.).
Stephan
S
Willems
From the Department of Electrophysiology, University Heart Center (D.S., M.F., A.S., H.S., B.A.H., J.L., B.S., S.W., D.S.) and Department of Medical Biometry and Epidemiology (K.W., S.L.), University Hospital Eppendorf, Hamburg, Germany; II Medical Clinic, Department of Electrophysiology, Johannes-Gutenberg University, Mainz (T.R.); and Center for Electrophysiology at Klinikum Links der Weser, Bremen, Germany (I.B.).
Daniel
D
Steven
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D001282:Atrial Flutter / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D017115:Catheter Ablation / Q000009:adverse effects; D018572:Disease-Free Survival; D015716:Electrocardiography, Ambulatory; D005260:Female; D005500:Follow-Up Studies; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D012737:Sex Factors; D013617:Tachycardia, Supraventricular / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
D000889:Anti-Arrhythmia Agents
arrhythmia (heart rhythm disorders); atrial fibrillation; catheter ablation; long-term outcome; stepwise approach; success