Background: Diagnosis-to-ablation time (DAT) of less than 1 year improves outcome and encourages earlier referral. The linear relation between DAT and outcome suggests that DATs of <1 year could further improve outcome.
Aims: 1. To determine whether a linear relation persists and/or whether a threshold can be defined within a DAT of <1 year. 2. To assess temporal trends in efficacy, safety and patient profile over time.
Methods and results: Two cohorts of 1,000 patients with atrial fibrillation (AF) (69% males, age 62 ± 10 years) undergoing pulmonary vein isolation (PVI) (2006–2014 and 2017–2019) were followed for 3 years. Primary outcome was clinical success, defined as freedom of documented AF without anti-arrhythmic drugs (AADs) respecting a 1-month blanking period. At 3 years, clinical success was achieved in 61.7% of patients, improving from 55.2% to 68.2% (p<0.001) over time. Complication rate decreased from 99 to 77 (p<0.001). DAT (48 ± 47 versus 35 ± 60; p=0.001) and number of previous AADs (2.1 ± 0.8 to 1.4 ± 0.8; p<0.001) decreased, while % female patients (28.3% to 33.5%; p=0.013), age (60 ± 10 years to 64 ± 10 years; p<0.001), % paroxysmal AF (58.5 to 63.8; p=0.015), underlying structural heart disease (19.8% to 28%; p<0.001) and CHA2DS2-VASc (1 ± 1 to 2 ± 1.5; p<0.001) increased over time. DAT analysis was done in 1,892 patients divided into 3 groups according to the DAT: DAT ≤6 months (n=503), DAT 6–12 months (n=242) and DAT >12 months (n=1147). Independent predictors of clinical success were age (HR 1.01, 95% CI 1.01–1.02; p=0.003), AF type (HR 0.54, 95% CI 0.46–0.63; p<0.0001), left atrial size (HR 1.05, 95% CI 1.03–1.06; p<0.0001), DAT (HR 1.00, 95% CI 1.00–1.00; p=0.001) and ablation technique (p=0.01) in multivariable-adjusted analysis. The highest clinical success was achieved when PVI was performed ≤6 months, and gradually declined with increasing DAT: 72.8% for DAT ≤6 months, 64.9% for DAT 6–12 months and 56.2% for DAT >1 year (p<0.001). Within 6 months, no difference in outcome was seen: 73.2%, 72.1% and 73.4% for DAT 0–2 months, 2–4 months and 4–6 months, respectively.
Conclusion: Despite ablation in higher‐risk patients, long-term efficacy increased over time with an improved safety profile. Our data advocate for early PVI following diagnosis of AF, with a DAT threshold of 6 months.
