Discussion
We compared the procedural characteristics and short-term clinical
outcomes of RF ablation of AF in young adults and older adults in this
study. Our series demonstrated Patients with young AF have a better
chance of being AF-free without the use of antiarrhythmic medications
than older patients.
AF is strongly age-dependent, affecting 4% of people over the age of 60
and 8% of people over the age of 80. The prevalence of AF is 0.1% in
people under the age of 55[14,15]. A large number
of studies focused on catheter ablation and stroke treatment in elderly
patients [16,17]. In previous studies, younger
patients were under-represented. Julian Chun reported 7243 AF ablation
patients in the German Ablation Registry collected from 51 German
centers between March 2007 and September 2012 revealed that only 8.2%
of patients were under the age of 45[9]. Ghannam
demonstrated From January 2000 to January 2019, radiofrequency energy
was administered to 82 of 6336 consecutive patients with AF. Because of
limited data on procedural characteristics and clinical outcome of
catheter ablation in young adults, we are paying closer attention to
these patients.
Catheter ablation is recommended as first-line therapy in selected
patients with AF and for drug-refractory AF in
adults[18,19]. In our study, 77% of the young
patients and 67% of the old patients were free of recurrent atrial
arrhythmias. There are numerous reasons why younger patients may fare
better than older patients. Firstly, the dilation of the atrial
structure in AF patients, a feature of atrial remodeling, has been
identified as a significant predictor of AF recurrence following
catheter ablation. Our data revealed that younger patients had smaller
atria, which could be a protective factor. And only the older population
(21.7%) had LA scars or Low-voltage areas on voltage maps, indicating
LA strutural alterations and fibrosis, compared to the very young
population, which all had normal voltage maps[20].
Secondly, in older patients, other poor ablation risk factors such as
hypertension, obesity, and obstructive sleep apnea syndrome were higher.
However, shorter preablation presence of these risk factors and easier
lifestyle modifications after PVI in young patients may explain the
differences with old patients[21,22].
Concerning complications, the overall complication rate was low.
Clinically significant serious adversee (including death, stroke, TIA)
occurred in 120 patients during 6334 procedures. There are several
factors that contribute to our study’s lower complication rate. To
begin, Spragg[23]et al identified
age>70 years as a predictor of major complications. The
mean age in our cohort of patients was less than 60 years old, which may
have contributed to the lower complication rates. The next, another
possible explanation is that 80% of the patients in the population were
male atrial fibrillation. There were gender differences in AF
patients[24,25]. Cheng[26]conducted a meta-analysis of 151370 patients, 34% of whom were women,
and discovered that women who underwent catheter ablation of AF may have
a higher risk of stroke/TIA and major complications than men, and that
genetic, vascular biology, hormonal, or thromboembolic factors that
differ between men and women may lead to a higher risk of
complications[27,28]. Furthermore, the included
population has a relatively high proportion of patients with paroxysmal
atrial fibrillation. Patients with persistent atrial fibrillation
require longer surgery time and more complex surgical procedures(such as
linear ablation, Marshall ligament) could be be accompanied by higher
complication rates [29,30]. Advances in ablation
technology, such as irrigation and contact force sensing, as well as
better management of AF risk factors may have contributed to this
improvement[31], which is also the cause of fewer
surgical complications.
Recently, The Early Treatment of Atrial Fibrillation for Stroke
Prevention Trial (EAST-AFNET 4) trial looked at the effectiveness of an
early rhythm-control strategy in patients who had recently been
diagnosed with AF (enrolled median 36 days after AF diagnosis), Early
rhythm control reduced the composite primary outcome of cardiovascular
death, stroke, and hospitalization for worsening heart failure and acute
coronary syndrome by 21% (from 5.0%/year to 3.9%/year) in this
trial[32].While AAD therapy has been definitively
proven to be superior to placebo in the prevention of arrhythmia
recurrence,but the young AF patient must accept a ”lifetime” daily
intake of AAD as part of a medical rhythm control plan, as well as the
possibility of accumulative side effects, leading to high rates of
withdrawn(OR 1.63-2.91)[33]. It’s interesting to
note that young patients had a rate of patients who needed particular
AAD treatment and anticoagulant drugs even after catheter ablation that
was substantially lower, showing that AF control is more likely to be
achieved, this finding is consistent with the CHADS2 and
CHA2DS2-VASc scores’ predictions of a
lower prevalence of comorbidities and thromboembolic
events[34].
AF is a chronic progressive disorder[35]. Age and
underlying comorbidities are associated with the natural progression
rate of PAF to persistent AF, which can reach up to 24.7% over the
course of 5 years[36]. After catheter ablation of
paroxysmal AF, recent long-term follow-up data showed an unexpectedly
low progression rate to permanent AF[37]. Based on
this observation, it may be preferable to do an early AF ablation in the
young patient rather than waiting until AF has developed into persistent
AF, which may then require a lengthy ablation treatment with a lower
chance of success[38]. The better outcome was
probably caused by younger patients having less electroanatomical
remodeling than older patients[39].To better
explain the positive response younger patients demonstrated in
comparison to the propensity-matched older group, a more extensive
assessment of the electroanatomic substrate (such as high-density
mapping, evaluation of cardiac fibrosis, and atrial mechanical
characteristics) is required.
Study Limitations
The primary limitation of our study is that the data is observational,
which makes it susceptible to selection bias. Large registry data, as
opposed to controlled randomized trials, may provide additional
information to help clarify treatment plan selection and outcome in a
”real world” setting. Second, the decision to use RF or CB ablation was
left up to the operators, and the CB method was used differently in
different centers. These factors may have influenced the findings, but
additional subgroup analysis is not possible given the available data.
Third, most studies lacked detailed information on factors such as
perioperative drug use, structural heart disease, obesity, and excessive
activity, as well as AF in the family. Fourth, most of the follow-up
reported in these trials was limited to 12 months. Longer-term follow-up
is needed to determine the outcome’s durability in terms of arrhythmia
recurrence,healthcare utilization.
Conclusion
According to data from our meta-analysis, young adults who undergo
catheter ablation of AF have greater 1-year success rates. In compared
to the older group, the young patients tended to have comparable rates
of complications (stroke/TIA, hematoma, cardiac tamponade, and
pericardial effusion).
Conflict of interest
On behalf of all authors, the corresponding author states that there is
no conflict of interest influenced by the article’s content.
Funding
The project was supported by funding from the following: the National
Natural Science Foundation of China [82060075];
References
1.McNamara DA, Chopra R , Ganatra RB. Early Rhythm Control in Atrial
Fibrillation.NEW ENGL J MED. 2021-02-04;384(5):483.
2.Gales L, Lipsker D. Cryoablation as Initial Therapy for Atrial
Fibrillation.NEW ENGL J MED. 2021-05-27;384(21):e82.
3. Andrade JG, Wells GA, Deyell MW, et al.Cryoablation or Drug Therapy
for Initial Treatment of Atrial Fibrillation.NEW ENGL J MED.
2021-01-28;384(4):305-315.
4.Kirchhof P, Camm AJ, Goette A, et al.Early Rhythm-Control Therapy in
Patients with Atrial Fibrillation.NEW ENGL J MED.
2020-10-01;383(14):1305-1316.
5.Tsiachris D, Doundoulakis I, Tsioufis K, et al.Pharmacologic
Cardioversion of Paroxysmal Atrial Fibrillation in the Emergency
Department in the Novel Anticoagulants’ Era.CARDIOVASC DRUG THER.
2022-12-01;36(6):1253-1254.
6.Wang C, Sun Y, Xin Q, et al.Visit-to-visit SBP variability and risk of
atrial fibrillation in middle-aged and older populations.J HYPERTENS.
2022-12-01;40(12):2521-2527.
7.Baimbetov AK,Bizhanov KA, Jukenova AM, et al.Comparative Effectiveness
and Safety of Cryoablation Versus Radiofrequency Ablation Treatments for
Persistent Atrial Fibrillation.AM J CARDIOL. 2022-12-01;184:22-30.
8.Leong-Sit P, Zado E, Callans DJ, et al. Efficacy and risk of atrial
fibrillation ablation before 45 years of age.CIRC-ARRHYTHMIA ELEC.
2010-10-01;3(5):452-7.
9.Chun KR, Schmidt B, Kuck KH, et al.Catheter ablation of atrial
fibrillation in the young: insights from the German Ablation Registry.
CLIN RES CARDIOL. 2013-06-01;102(6):459-68.
10. Allam L, Samir R, Ali AN, et al. Clinical outcomes of catheter
ablation of paroxysmal atrial fibrillation in very young population
compared to older population: a prospective study. EGYPT HEART J.
2019-09-16;71(1):11.
11. Bergau L, El Hamriti M, Rubarth K, et al. Cool enough? Lessons
learned from cryoballoon-guided catheter ablation for atrial
fibrillation in young adults. J CARDIOVASC ELECTR.
2020-11-01;31(11):2857-2864.
12. Tijskens M, Bergonti M, Spera F, et al.Etiology and Outcome of
Catheter Ablation in Patients With Onset of Atrial Fibrillation
<45 Years of Age.AM J CARDIOL. 2022-03-01;166:45-52.
13. Ghannam M, Chugh A, Bradley DJ, et al. Clinical characteristics and
long-term outcomes of catheter ablation in young adults with atrial
fibrillation. J INTERV CARD ELECTR. 2022-08-01;64(2):311-319.
14.Pilotto A, Veronese N, Polidori MC, et al.The role of prognostic
stratification on prescription of anticoagulants in older patients with
atrial fibrillation: a multicenter, observational, prospective European
study (EUROSAF).ANN MED. 2022-12-01;54(1):2411-2419.
15.Curtis AB, Zeitler EP, Malik A, et al.Efficacy and safety of
dronedarone across age and sex subgroups: a post hoc analysis of the
ATHENA study among patients with non-permanent atrial
fibrillation/flutter.EUROPACE. 2022-11-22;24(11):1754-1762.
16.Guo Y, Romiti GF, Proietti M, et al.Mobile health technology
integrated care in older atrial fibrillation patients: a subgroup
analysis of the mAFA-II randomised clinical trial.AGE AGEING.
2022-11-02;51(11).
17.Cecchini F, Mugnai G, Iacopino S, et al.Safety and long-term efficacy
of cryoballoon ablation for atrial fibrillation in octogenarians: a
multicenter experience.J INTERV CARD ELECTR. 2022-11-01;65(2):559-571.
18.Khachatryan A, Merino JL, de Abajo FJ, et al.International cohort
study on the effectiveness of dronedarone and other antiarrhythmic drugs
for atrial fibrillation in real-world practice (EFFECT-AF).EUROPACE.
2022-07-15;24(6):899-909.
19.Cardoso R, Justino GB, Graffunder FP, et al.Catheter Ablation is
Superior to Antiarrhythmic Drugs as First-Line Treatment for Atrial
Fibrillation: a Systematic Review and Meta-Analysis.ARQ BRAS CARDIOL.
2022-07-01;119(1):87-94.
20. Kim HJ, Chang DH, Kim SO, et al.Left atrial appendage preservation
versus closure during surgical ablation of atrial fibrillation.HEART.
2022-11-10;108(23):1864-1872.
21.Rordorf R, Iacopino S, Verlato R, et al.Role of CHA2DS2-VASc score in
predicting atrial fibrillation recurrence in patients undergoing
pulmonary vein isolation with cryoballoon ablation.J INTERV CARD ELECTR.
2022-11-23.
22.Intzes S, Zagoridis K, Symeonidou M, et al.P-wave duration and atrial
fibrillation recurrence after catheter ablation: a systematic review and
meta-analysis.EUROPACE. 2022-11-22
23.Spragg DD, Dalal D, Cheema A, et al.Complications of catheter
ablation for atrial fibrillation: incidence and predictors.J CARDIOVASC
ELECTR. 2008-06-01;19(6):627-31.
24.Park YJ, Park JW, Yu HT, et al.Sex difference in atrial fibrillation
recurrence after catheter ablation and antiarrhythmic drugs.HEART.
2022-11-07
25.Siddiqi HK, Vinayagamoorthy M, Gencer B, et al.Sex Differences in
Atrial Fibrillation Risk: The VITAL Rhythm Study.JAMA CARDIOL.
2022-10-01;7(10):1027-1035.
26.Cheng X, Hu Q, Gao L, et al.Sex-related differences in catheter
ablation of atrial fibrillation: a systematic review and
meta-analysis.EUROPACE. 2019-10-01;21(10):1509-1518.
27.Noubiap JJ, Thomas G, Agbaedeng TA, et al. Sex differences in
clinical profile, management, and outcomes of patients hospitalized for
atrial fibrillation in the United States.EUR HEART J-QUAL CAR.
2022-11-17;8(8):852-860.
28.Park YJ, Park JW, Yu HT, et al.Sex difference in atrial fibrillation
recurrence after catheter ablation and antiarrhythmic drugs.HEART.
2022-11-07
29.Baimbetov AK, Bizhanov KA, Jukenova AM, et al.Comparative
Effectiveness and Safety of Cryoablation Versus Radiofrequency Ablation
Treatments for Persistent Atrial Fibrillation.AM J CARDIOL.
2022-12-01;184:22-30.
30.Lo M, Nair D, Mansour M, et al.Contact force catheter ablation for
the treatment of persistent atrial fibrillation: Results from the
PERSIST-END study. J CARDIOVASC ELECTR. 2022-11-09.
31.Cao ZJ, Guo XG, Sun Q, et al.Cryoballoon ablation of persistent
atrial fibrillation for de novo pulmonary vein isolation: a
single-center follow-up study.J GERIATR CARDIOL.
2022-10-28;19(10):725-733.
32.Deshpande R, AlKhadra Y, Singanallur P, et al.Outcomes of catheter
ablation versus antiarrhythmic therapy in patients with atrial
fibrillation: a systematic review and meta-analysis.J INTERV CARD
ELECTR. 2022-09-03.
33. Andrade JG, Deyell MW, Dubuc M, et al.Cryoablation as a first-line
therapy for atrial fibrillation: current status and future
prospects.EXPERT REV MED DEVIC. 2022-08-01;19(8):623-631.
34.Osmancik P, Havránek Š, Bulková V, et al.Catheter ablation versus
antiarrhythmic drugs with risk factor modification for treatment of
atrial fibrillation: a protocol of a randomised controlled trial
(PRAGUE-25 trial).BMJ Open. 2022-06-15;12(6):e056522.
35. Bortman LV, Mitchell F, Naveiro S, et al.Direct Oral Anticoagulants.
An Updated Systematic Review of its Clinical Pharmacology and Clinical
Effectiveness and Safety in Patients with Nonvalvular Atrial
Fibrillation.J CLIN PHARMACOL. 2022-11-25.
36.Curtis AB, Zeitler EP, Malik A, et al.Efficacy and safety of
dronedarone across age and sex subgroups: a post hoc analysis of the
ATHENA study among patients with non-permanent atrial
fibrillation/flutter.EUROPACE. 2022-11-22;24(11):1754-1762.
37.von Falkenhausen AS, Feil K, Sinner MF, et al.Atrial Fibrillation
Risk Assessment after Embolic Stroke of Undetermined Source.ANN NEUROL.
2022-11-13.
38.Jin Y, Wang K, Xiao B, et al.Global burden of atrial
fibrillation/flutter due to high systolic blood pressure from 1990 to
2019: estimates from the global burden of disease study 2019.J CLIN
HYPERTENS. 2022-11-01;24(11):1461-1472.
39. Andrade JG, Deyell MW, Macle L, et al.Progression of Atrial
Fibrillation after Cryoablation or Drug Therapy.NEW ENGL J MED.
2022-11-07.
Table 1 Baseline characteristics of the included studies