Impact of response to electrical cardioversion before catheter ablation for persistent atrial fibrillation: a propensity score-matched analysis

Abstract Aims We hypothesize that sinus rhythm (SR) maintenance in persistent atrial fibrillation (AF) patients taking anti-arrhythmic drugs (AADs) after pre-procedural electrical cardioversion (ECV) could predict outcomes after catheter ablation procedures. Methods and results 219 persistent AF patients on AADs underwent ECV 1–6 months before ablation. Patients were categorized into two groups according to their response to ECV: patients in whom SR was restored and maintained until the ablation procedure (ECV-SR group), and patients with AF recurrence before the procedure (ECV-AF group). Then, 1:1 propensity score matching was used to create study groups (94–94 patients). The efficacy outcomes of the present study were freedom from atrial tachyarrhythmia on/off AADs following a single ablation procedure and recurrence of persistent AF. The median follow-up duration was 42 (20–73) months. Freedom from atrial tachyarrhythmia at 36 months was lower in the ECV-AF group compared to ECV-SR patients (31.4% vs. 51.2%, respectively; crude HR = 2.58, 95% CI = 1.58–3.70, P < 0.001). The most frequent pattern of atrial arrhythmia recurrence was persistent AF in the ECV-AF group and paroxysmal AF in the ECV-SR group. Freedom from persistent AF at 36 months was 54% and 84.3%, respectively (crude HR = 3.72, 95% CI = 1.94–7.14, P < 0.001). Differences in the risk of the efficacy outcomes were similar after multi-variable adjustment and in all analysed subgroups, including pulmonary vein isolation (PVI)-only procedures. Conclusion Our findings indicate that the positive response to pre-procedural ECV may be a valuable marker for identifying persistent AF patients in whom a PVI-only strategy is sufficient.