Sinus rhythm restoration and arrhythmia noninducibility are major predictors of arrhythmia-free outcome after ablation for long-standing persistent atrial fibrillation: A prospective study

BACKGROUND The impact of restoring sinus rhythm (SR) by initial ablation in patients with long-standing persistent atrial fibrillation (LSPAF) is not fully established. OBJECTIVE The purpose of this study was to investigate the prognostic value of SR restoration at the initial procedure and arrhythmia noninducibility at the final repeat procedure for long-term outcome. METHODS A total of 203 patients (22% female; age 59 9 years underwent stepwise catheter ablation for LSPAF. RESULTS The procedural end-point of SR restoration was achieved in 50% of patients. During follow-up (median 48 months) and after 1.7 procedures per patient, 72% of patients were free from arrhythmia off antiarrhythmic drugs. Failure to restore SR was independently predicted by left atrial (LA) long-axis diameter >= 68 mm (relative risk [RR] 1.55, P = .03], proportion of high-voltage LA sites <20% (RR 1.62, P = .02), and left atrial appendage (LAA) atrial fibrillation cycle length (AFCL) <155 ms (RR 1.5, P = .05). Arrhythmia recurrence after the initial procedure was predicted by SR nonrestoration (RR 2.99, P < .000001) and LAA AFCL >= 155 ms (RR 1.90, P = .0002). Arrhythmia recurrence after the final procedure was predicted by SR nonrestoration at the initial procedure (RR 2.83, P = .0007), persistent AF duration >= 24 months (RR 2.74, P = .002), LAA outflow velocity <40 cm/s (RR 2.21, P = .006), and LAA AFCL >= 155 ms (RR 1.92, P = .02). In 115 patients with repeat procedure(s), failure to achieve arrhythmia noninducibility at the final procedure (19% of patients) was associated with arrhythmia recurrence (RR 8.9, P < .000001). CONCLUSION SR restoration at the initial procedure and arrhythmia noninducibility at the last repeat procedure were major predictors of arrhythmia-free outcome after ablation for LSPAF.