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Circ Arrhythm Electrophysiol. Author manuscript; available in PMC 2024 Jun 1.
Published in final edited form as:
Circ Arrhythm Electrophysiol. 2023 Jun; 16(6): e011565.
Published online 2023 May 15. doi:10.1161/CIRCEP.122.011565
PMCID: PMC11093280
NIHMSID: NIHMS1894133
PMID: 37183675
Brett M. Johnson, MD, Oussama M. Wazni, MD, Medhat Farwati, MD, Walid I. Saliba, MD, Pasquale Santangeli, MD, Ruth Madden, MPH, Patricia Bouscher, BSN, Mina Chung, MD, Mohamed Kanj, MD, Thomas J. Dresing, MD, Thomas D. Callahan, MD, Mandeep Bhargava, MD, Bryan Baranowski, MD, John Rickard, MD, Daniel J. Cantillon, MD, Patrick J. Tchou, MD, Jakub Sroubek, MD, Hiroshi Nakagawa, MD, and Ayman A. Hussein, MD
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The publisher's final edited version of this article is available at Circ Arrhythm Electrophysiol
Abstract
Background:
Ablation is used for both rhythm control and improved quality of life (QoL) in atrial fibrillation (AF). It has been suggested that young adults may experience high recurrence rates after ablation and data remain lacking regarding QoL benefits. We aimed to investigate AF ablation outcomes and QoL benefits in young adults undergoing AF ablation using a large prospectively maintained registry and automated patient reported outcomes (PRO).
Methods:
All patients undergoing AF ablation (2013–2016) at our center were prospectively enrolled. Patients 50 years or younger were included. For PROs, QoL measures and symptoms were assessed at baseline, 3 months after ablation, and every 6 months thereafter. The AF severity score (AFSS) served as the main assessment of QoL.
Results:
A total of 241 young adults (ages 16–50) were included (17% female, 40.3% persistent AF). In all, 77.2% of patients remained arrhythmia-free during the first year of follow-up (80% in non-structural AF, 66% in structural AF). Using PROs, 90% of patients reported improvement in QoL throughout all survey time points up to 5 years post-ablation (P<0.0001). The baseline median AFSS was 14 and improved to between 2 and 4 on all follow-up after ablation (P<0.0001). Patients also reported fewer and shorter AF episodes, fewer ER visits secondary to AF, and fewer hospitalizations (P<0.0001).
Conclusion:
Ablation remains an effective rhythm-control strategy in young adults with AF. Young adults also experience significant improvement in QoL with reduction of the frequency and duration of AF episodes and AF-related healthcare utilization.
Graphical Abstract
Introduction
Atrial fibrillation (AF) is the most common cardiac arrhythmia and has become a public health problem.1 Ablation is one of the mainstays of AF rhythm-control strategies and is commonly performed for symptomatic improvement in patients.2 However, ablation outcomes are predominantly reported in terms of arrhythmia recurrence without data on patient reported outcomes (PRO), moreover PRO over time. The use of PRO is increasingly emphasized to drive patient-centered care but has not been widely adopted mostly due to logistical issues and lack of financial incentives to support its implementation.3 In AF ablation research in particular, only 14% of studies from 1999 to 2018 included PRO of any kind.4
While the risk of AF increases with age, clinical practice would suggest younger patients may be more symptomatic and hesitant to take long-term medications. This makes durable rhythm control more desirable in younger patients; with ablation being a strategy that has the potential to eliminate the need for life-long anti-arrhythmic drugs. However, only limited data exist regarding younger adults after AF ablation, PRO or otherwise. It has been suggested that arrhythmia recurrences in younger patients vary between 16% and 56%, with better control noted in closer follow-up using multiple procedures and anti-arrhythmic drugs.5–7 However, the quality of life benefit through PROs has not been assessed.
In the present study, we set out to further define arrhythmia-free survival and quality of life PROs in younger patients undergoing catheter ablation.
Methods
The current study was approved by the institutional review board at the Cleveland Clinic. All patients provided consent prior to ablation procedures. The data from this study will be made available from the corresponding author on reasonable request for the purposes of reproducing results or replicating the procedure.
AF Ablation and Clinical Follow-Up
Patients were selected from a prospectively maintained AF registry which includes all patients undergoing ablation at our center from 2013 to 2016. In the registry, procedural and outcomes data are prospectively collected at baseline and during follow up. Patients aged 50 years or younger were included in line with prior studies.5–7 All patients underwent either radiofrequency or cryoablation targeting isolation of the pulmonary veins (PVI). Additional ablations targeting other areas were performed at the discretion of the operator. Clinical covariates were recorded prior to the ablation procedure, on the day of ablation, and at subsequent follow-up visits. Arrhythmia monitoring included heart rhythm transmitters for 3–4 months after ablation and cardiac implantable device data, such as pacemakers, loop recorders or defibrillators whenever available. Patients were instructed to transmit tracings whenever symptomatic as well as on a weekly basis even when asymptomatic. Additional event recorder monitoring was obtained beyond the 3-months period for patients with documented arrhythmia and those who developed symptoms concerning for arrythmias in the initial 3-months period. Patients also underwent clinic visit assessments with 12-lead electrocardiograms at 3, 6, and 12 months. Arrhythmia recurrence was defined per guidelines as electrocardiographic documentation beyond a 3-month blanking period of an atrial tachyarrhythmia lasting >30 s, on a 12-lead ECG, event recording, or Holter monitor recording. The arrhythmia recurrence rates (in line with conventional ablation outcome measures) were systematically evaluated over 1 year of follow-up with in-person visits in cardiac electrophysiology clinics. Beyond one year, only patient reported outcomes for QoL assessment were employed. This is primarily used to enhance outcomes data collection at our tertiary care center with a national/ international referral base; as previously described.8
Automated Patient Reported Outcomes Remote System
An automated remote follow-up system for PRO data collection was designed and built by the Cleveland Clinic Section of Cardiac Electrophysiology and Pacing (Cleveland, OH) in conjunction with the Human-Computer Interaction Institute at Carnegie Mellon University (Pittsburgh, PA). The development and implementation of this system was previously described by our team.8
Ten days prior to a scheduled ablation procedure, the PRO system automatically sent an email invitation to complete the PRO survey. Following the procedure, patients received similar invitations at 3 months, 6 months, and every 6 months after for a total duration of 5 years.
Patient Reported Outcomes in AF Ablation
The automated PRO system was used to collect healthcare utilization and quality of life (QoL) measures in patients undergoing AF ablation at our center primarily through the atrial fibrillation severity scale (AFSS), a validated questionnaire focusing on symptom severity to measure QoL in patients with AF.9–11 The AFSS asks patients to rate 7 symptoms from a score of 0 (no symptoms) to 5 (worse symptoms) with overall scores reported as a sum of all 7 AF-related symptoms. Total scores can range from 0 and 35 with higher scores indicating worse symptoms and poorer QoL. In addition to the AFSS, the automated survey also collected information regarding AF frequency and duration of events, AF-associated healthcare utilization including emergency room visits and hospitalizations, and patient-reported clinical improvement; as previously reported by our team.8
Statistical Analyses
We investigated arrhythmia recurrence rates and the impact of ablation on QoL with measures of the AFSS, AF frequency and duration, patient-reported clinical improvement, and AF-associated healthcare utilization. All statistical analyses were performed using Stata Release 17 (College Station, TX). Continuous variables are presented as mean±SD or median (interquartile range) as appropriate. The χ2 test was used to compare proportions of categorical variables. The ANOVA or nonparametric Wilcoxon rank-sum test were used as appropriate for continuous variables. A 2-sided P value <0.05 was considered statistically significant.
Results
Baseline Characteristics
Between 2013 and 2016, 241 patients aged 16–50 years old underwent AF ablation at our institution. Patients were 43.1±7.3 years old on average, with 83% being males. The average body mass index (BMI) was 31.0±6.3 kg/m2. In 59.3% of patients, ablation was performed for paroxysmal AF while 40.3% underwent ablation for persistent AF. The majority of patients did not have structural heart disease (75.1%), whereas 7.1% had valvular heart disease and 17.9% had cardiomyopathy. Prior to ablation, 39% of patients reported being in AF at the time of the baseline survey. Further baseline statistics are summarized in Table 1.
Table 1:
Baseline Characteristics
| n | % | |||
|---|---|---|---|---|
| Age (years): | Mean | 43.1±7.3 | ||
| 30 and Under | 20 | |||
| 31–40 | 48 | |||
| 41–50 | 173 | |||
| BMI | 31.0±6.3 | |||
| Gender | ||||
| Male | 200 | 83 | ||
| Female | 41 | 17 | ||
| Race | ||||
| White | 211 | 87.6 | ||
| Black | 9 | 3.7 | ||
| Asian | 2 | 0.8 | ||
| American Indian/Alaska Native | 1 | 0.4 | ||
| Multiracial | 15 | 6.2 | ||
| Declined | 3 | 1.2 | ||
| Ethnicity | ||||
| Hispanic | 7 | 2.9 | ||
| Non-Hispanic | 233 | 96.7 | ||
| Declined | 1 | 0.4 | ||
| AF without Structural Heart Disease | 181 | 75.1 | ||
| Structural Heart Disease | ||||
| Valvular | 17 | 7.1 | ||
| Cardiomyopathy | 43 | 17.9 | ||
| Hypertension | 62 | 25.8 | ||
| Diabetes Mellitus | 14 | 5.8 | ||
| Smoking Status | ||||
| Never | 164 | 73.5 | ||
| Current | 17 | 7.6 | ||
| Past | 42 | 18.8 | ||
| Alcohol Use | 47 | 21.4 | ||
| Type of AF | ||||
| Paroxysmal | 143 | 59.3 | ||
| Persistent | 97 | 40.3 | ||
| Unknown | 1 | 0.4 | ||
| CHA2DS2-VASC | ||||
| Median | 0 (0–1) | |||
| 0 | 159 | 66 | ||
| 1 | 47 | 19.5 | ||
| 2 | 19 | 7.9 | ||
| 3 | 5 | 2.1 | ||
| 4 | 11 | 4.6 | ||
| Presented in AF at Ablation | 60 | 25.3 | ||
| Anticoagulation Before Ablation | ||||
| Warfarin | 43 | 17.8 | ||
| Dabigatran | 39 | 16.3 | ||
| Rivaroxaban | 85 | 35.4 | ||
| Apixaban | 72 | 30 | ||
| Antiarrhythmic Drug Therapy | ||||
| Flecainide | 37 | 18.9 | ||
| Amiodarone | 8 | 4.2 | ||
| Sotalol | 15 | 7.8 | ||
| Dofetilide | 24 | 12.5 | ||
| Propafenone | 14 | 7.5 | ||
| Dronedarone | 7 | 3.7 | ||
| Rate Control Drug Therapy | ||||
| Beta Blocker | 147 | 61 | ||
| Calcium-Channel Blocker | 42 | 17.4 | ||
| Total | 241 |
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All patients underwent pulmonary vein isolation. Of the PVIs, 93.4% of patients underwent radiofrequency (RF) ablation with the remaining 6.6% undergoing cryoablation. In all patients undergoing radiofrequency ablation, the posterior wall was ablated. Isoproterenol was used in 14.3% of patients, inducing premature atrial contractions (PAC) in two patients and atrial tachycardia (AT) in one patient. Additional ablation targets were up to operators’ discretion. The cavotricuspid isthmus (CTI) was ablated in 18.3% of patients. Concomitant arrhythmia ablations otherwise included PAC ablation in 3.3%, AT ablation in 2.5%, slow pathway ablation in 1.2%, and accessory pathway ablation in 0.4% of patients.
Arrhythmia Recurrence
During one year of clinical follow-up, 77.2% of patients remained arrhythmia-free. For patients without structural heart disease, 80% of patients remained arrhythmia-free at the 1-year mark, while 66% of patients with structural heart disease remained arrhythmia-free after 1 year of follow-up. In patients with paroxysmal AF, 78.3% of patients remained arrhythmia-free over the 1-year follow-up period as compared to 75.3% of patients with persistent AF. Similarly, 75% of patients undergoing cryoablation remained arrhythmia-free, whereas 77.3% of patients undergoing RF ablation were arrhythmia-free at the one-year timepoint. In patients who did experience arrhythmia recurrence, 78% had documented recurrent AF. The next most common mode of arrhythmia recurrence was atrial flutter (AFL) at 11%, followed by a combination of AF and AFL at 7%. The remaining 4% had AT.
Age, sex, BMI, type of AF, and baseline AFSS were not significantly different between those patients with recurrence and those without recurrence. Similarly, there was no difference between comorbid conditions in the two groups including hypertension, diabetes, coronary artery disease, congestive heart failure, or valvular heart disease. Patients with recurrence were more likely to have had a stroke (7.6% vs 1.7% without recurrence; P=0.02) and have had prior valve surgery (6.3% vs 1.7%, P=0.04) (Table 2).
Table 2:
Clinical Characteristics of Patients Based on Recurrence of Atrial Fibrillation Post-Ablation
| No Recurrence (n=186) | Recurrence (n=55) | P value | |
|---|---|---|---|
| Age, y | 42.6±7.7 | 44.3±6.0 | 0.15 |
| Females | 29 (15.6) | 12 (18.2) | 0.28 |
| Baseline AFSS score | 14 (7–22) | 14 (7–24.5) | 0.76 |
| AF type-paroxysmal | 112 (60.2) | 31 (56.4) | 0.74 |
| BMI, kg/m2 | 31±6.6 | 32.1±8.1 | 0.9 |
| Active Smoking | 10 (5.8) | 8 (13.6) | 0.09 |
| Alcohol consumption | 34 (19.8) | 17 (29.3) | 0.35 |
| CAD | 5 (2.7) | 2 (3.0) | 0.72 |
| Valvular heart disease | 10 (5.4) | 7 (10.6) | 0.07 |
| Cardiomyopathy | 30 (16.2) | 14 (21.2) | 0.21 |
| CHF | 5 (2.7) | 1 (1.5) | 0.71 |
| HTN | 48 (26.0) | 19 (28.8) | 0.94 |
| DM | 9 (4.9) | 7 (10.6) | 0.24 |
| Chronic pulmonary disease | 4 (2.2) | 2 (3.0) | 0.88 |
| Stroke | 3 (1.6) | 5 (7.6) | 0.02 |
| PCI | 2 (1.1) | 0 (0) | 0.45 |
| Valve surgery | 3 (1.7) | 4 (6.3) | 0.04 |
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Numbers are presented as counts (percentages), mean±SD, or median (quartiles).
Patient Reported Outcomes Post-Ablation
Patient reported outcomes were collected during a 5-year period. In the first 36 months of follow-up, a total of 1113 invitations were sent to patients undergoing ablation. Of those, 544 surveys (48.9%) were started, and 512 surveys (46.0%) were completed. For the baseline survey, 100 patients started the baseline survey with 94 completing it (response rate 41.5%). At 12 months, 82 patients started the survey with 80 completing it (response rate 34%). At 36 months, 30 patients started the survey with 28 completing it (response rate 12.4%). Respondents answered an average of 3.34 surveys.
During the study follow-up, there was a significant improvement in QoL following ablation. The median AFSS was 14 (7–22) at baseline and was reduced to 4 or less for all time points during the follow-up (P<0.0001; Figure 1). Moreover, each of the individual symptom scores that comprise the AFSS had significant improvement post-ablation at all time points including palpitations, dyspnea at rest, dyspnea on exertion, exercise intolerance, fatigue, lightheadedness, and chest pain (Figure 2, P<0.0001). Patients undergoing RF ablation similarly reported a baseline median AFSS of 14 (7–22) which was reduced to 4 or less at all time points (P<0.0001). Patients undergoing cryoablation reported a median AFSS of 9 (9–9) at baseline with a reduction in score to 6 or less at all timepoints. Overall, 75.0% of younger patients reported marked improvement in their AF symptoms following ablation, while 11.5% reported moderate improvement, 6.6% reported mild improvement, and 7.0% reported no improvement (P<0.0001; Figure 3A and and3B).3B). This benefit was sustained during the follow-up period and was observed at each of the follow-up time points (Figure 3A).
Figure 1:
Automated patient-reported AF symptom severity scores comprised from 7 symptom domains.
Figure 2:
Improvement in individual components of the AF symptom severity score after ablation. Scores range from 0 (no symptoms) to 5 (worst symptoms). All scores are reported as medians.
Figure 3:
A. Improvement in atrial fibrillation-related symptoms (P<0.0001 at each time point). B. Overall reported symptoms improvement post-ablation, P<0.0001.
When comparing patients at the 12-month follow-up survey, respondents were more likely to be older (45.6±5.1 years vs. 41.9±7.9 years; P<0.01), more likely to consume alcohol (28.7% vs. 16.4%; P=0.01), and more likely to have undergone PCI (2.6% vs. 0%, P=0.04) when compared to nonrespondents. There were no other statistically significant differences between the groups. 73.8% (n=59) of patients reported marked improvement, 18.8% (n=15) reported mild to moderate improvement, and 7.5% (n=6) reported worse or no change in symptoms post-ablation. There was no significant difference between mean age, BMI, or AF type between the study groups. Baseline AFSS were also not significantly different across all groups (P=0.83). Female patients were more likely to report only mild to moderate improvement following ablation (P=0.04). Patients with coronary artery disease (CAD) or valvular heart disease were also more likely to report less improvement in AF symptoms post-ablation (P<0.01 for both groups). Similarly, patients who had undergone percutaneous coronary intervention or valvular surgery reported less improvement post-ablation (P<0.01 and P=0.01, respectively). There was no difference among the study groups for other comorbid conditions including active smoking, alcohol consumption, cardiomyopathy, heart failure, hypertension, diabetes mellitus, chronic pulmonary disease, or stroke (Table 3). The results of univariable regression analyses of clinical characteristics and their association with both marked improvement and no or worse improvement can be found in Table 4.
Table 3:
Clinical Characteristics of Patients Based on Clinical Response to Catheter Ablation at 12 Months
| Marked (n=59) | Moderate/Mild (n=15) | Worse or Unchanged (n=6) | P value | |
|---|---|---|---|---|
| Age, y | 45.1±6.5 | 46.3±5.0 | 48.0±1.9 | 0.46 |
| Females | 7 (11.9) | 6 (40.0%) | 1 (16.7) | 0.04 |
| Baseline AFSS score | 13.5 (7–24) | 17 (5–27) | 16 (10–24) | 0.83 |
| AF type-paroxysmal | 36 (61.0) | 8 (53.3) | 5 (83.3) | 0.44 |
| BMI, kg/m2 | 32.0±6.3 | 30.7±4.4 | 36.8±11.5 | 0.21 |
| Active Smoking | 3 (5.1) | 1 (6.7) | 1 (16.7) | 0.72 |
| Alcohol consumption | 14 (23.7) | 5 (33.3) | 1 (16.7) | 0.37 |
| CAD | 1 (1.7) | 0 (0) | 2 (33.3) | <0.01 |
| Valvular heart disease | 1 (1.7) | 4 (26.7) | 1 (16.7) | <0.01 |
| Cardiomyopathy | 9 (15.3) | 3 (20.0) | 2 (33.3) | 0.54 |
| CHF | 1 (1.7) | 0 (0) | 1 (16.7) | 0.07 |
| HTN | 13 (22.0) | 4 (26.7) | 4 (66.7) | 0.06 |
| DM | 3 (5.1) | 0 (0) | 1 (16.7) | 0.29 |
| Chronic pulmonary disease | 3 (5.1) | 0 (0) | 0 (0) | 0.57 |
| Stroke | 1 (1.7) | 1 (6.7) | 0 (0) | 0.5 |
| PCI | 0 (0) | 0 (0) | 1 (16.7) | <0.01 |
| Valve surgery | 0 (0) | 2 (13.3) | 0 (0) | 0.01 |
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Numbers are presented as counts (percentages), mean±SD, or median (quartiles).
AF indicates AF; AFSS, atrial fibrillation severity score; BMI, body mass index; CAD, coronary artery disease; CHF, congestive heart failure; HTN, hypertension; DM, diabetes mellitus; PCI, percutaneous coronary intervention.
Table 4:
Univariable Analyses of Clinical Characteristics’ Association with Ablation Response at 12 Months.
| Marked Improvement | Worse or No Improvement | ||||
|---|---|---|---|---|---|
| Univariable OR (95% CI) | P value | Univariable OR (95% CI) | P value | ||
| Age | 0.94 (0.84–1.05) | 0.27 | 1.16 (0.87–1.54) | 0.31 | |
| Females | 0.27 (0.08–0.90) | 0.03 | 0.94 (0.10–8.72) | 0.96 | |
| Baseline AFSS | 0.97 (0.92–1.05) | 0.53 | 1.01 (0.89–1.14) | 0.86 | |
| AF type-paroxysmal | 0.96 (0.35–2.68) | 0.94 | 3.41 (0.38–30.66) | 0.27 | |
| BMI, kg/m2; per 1 kg/m2 increments | 0.99 (0.91–1.08) | 0.83 | 1.10 (0.98–1.23) | 0.11 | |
| Active Smoking | 0.56 (0.09–3.61) | 0.54 | 3.25 (0.30–34.86) | 0.33 | |
| Alcohol consumption | 0.90 (0.29–2.77) | 0.85 | 0.52 (0.06–4.71) | 0.56 | |
| CAD | 0.17 (0.1–1.94) | 0.15 | 36.00 (2.67–486.18) | 0.01 | |
| Valvular heart disease | 0.06 (0.01–0.52) | 0.01 | 2.68 (0.26–27.58) | 0.41 | |
| Cardiomyopathy | 0.59 (0.17–2.01) | 0.4 | 2.54 (0.42–15.48) | 0.31 | |
| CHF | 0.35 (0.02–5.88) | 0.47 | 14.40 (0.78–266.00) | 0.07 | |
| HTN | 0.46 (0.16–1.34) | 0.16 | 6.71 (1.13–39.83) | 0.04 | |
| DM | 1.07 (0.11–10.90) | 0.46 | 4.73 (0.41–54.20) | 0.21 | |
| Chronic pulmonary disease | 1 (Omitted) | 1 (Omitted) | |||
| Stroke | 0.34 (0.02–5.77) | 0.46 | 1 (Omitted) | ||
| PCI | 1 (Omitted) | 1 (Omitted) | |||
| Valve surgery | 1 (Omitted) | 1 (Omitted) | |||
| Recurrent AF at 12 Months | 0.06 (0.01–0.51) | 0.01 | 8.75 (1.22–62.99) | 0.03 | |
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At the time of the baseline survey, 39% of patients reported being in AF (Figure 4A). On follow-up, this was 9.5% or lower for all subsequent time points (P<0.001). There was also a significant reduction in the AF duration and frequency scores, for which patients can rate the duration and frequency of their AF from 0 (none) to 10 (continuous) (P<.0001; Figure 4B and and4C4C).
Figure 4:
Frequency and duration of atrial fibrillation (AF). A. Proportion of patients in AF at time of survey completion. B. AF frequency score: A score ranging from 0 (none) to 10 (continuous). C. AF duration score: A score ranging from none (0) to continuous (10).
Similarly, healthcare utilization such as emergency room (ER) visits and hospitalizations also significantly decreased after ablation. Following the first year after ablation, 18.2% of patients or fewer reported ER visits related to AF, a significant decrease from 50% at baseline (P<0.0001;). Hospitalizations secondary to AF also declined from a baseline of almost 60% to 14.3% or less at the follow-ups after the first-year post-ablation (P<0.001).
Discussion
In this study, we demonstrate that AF ablation remains a viable strategy for both rhythm control and improvement in QoL for young adults with the disease. After ablation, 77.2% of patients remained arrhythmia-free over one year follow-up (78.3% in paroxysmal and 75.3% in persistent). In patients with structural heart disease, 66% remained arrhythmia-free. These data are similar to the lower rates of recurrence reported in more recent studies12,13 of AF ablation in young adults and in contrast with earlier reports which had suggested a rate of arrhythmia recurrence of 40–60%.7 These as well as other data support that young adults do as well as a more traditional patient population when looking at arrhythmia-free survival.
However, while arrhythmia-free survival is the typical outcome measured in most AF ablation studies, it is important to keep in mind that AF ablation is often performed in clinical practice to improve the QoL and symptoms of patients.14,15 The reduction of both the frequency and duration of events may translate into significant improvement in QoL despite “arrhythmia recurrence” in traditional guideline definitions. Reducing the symptoms or number of healthcare visits secondary to AF may also prove a successful outcome from the patient perspective, something overlooked in typical clinical research. Moreover, prior data suggest a discrepancy between traditional, physician-measured outcomes of AF ablation success and those of PROs, with PROs being more sensitive for symptom relief.16 For an intervention aimed to improve QoL such as ablation, we suggest that PROs should factor into the clinical decision-making when discussing AF ablation outcomes.
The present study describes such PROs for young adults undergoing AF ablation. In addition to arrhythmia-free survival, young adults report significant improvement in all measured symptom domains; including palpitations, chest pain, dyspnea at rest, dyspnea with activity, exercise intolerance, fatigue, and lightheadedness and this benefit is sustained over the follow-up period of 5 years in the current study. These patients also experienced significant reduction in emergency room visits or hospitalizations for AF. Careful evaluation of comorbid conditions, such as coronary artery disease or valvular heart disease, may also help identify who may respond better post-ablation.
While PROs can be difficult to collect among academic tertiary referral centers, this study again demonstrates an automated system is feasible to enhance data collection.8 In addition and in conjunction with traditional follow-up, automated PRO collection may aid in outcomes assessment and gaining key insight into the true benefits experienced by patients.
Study Limitations
The study is observational in nature making these data subject to known residual bias or confounding. While asymptomatic recurrences could be missed with PROs, the clinical benefit of improvement in QoL remains the most important target of AF ablation. The patients in the current study were also part of a single referral center performing mainly RF ablation and may not be representative of community practice. Moreover, the study population was predominantly comprised of obese, white, non-Hispanic males, limiting the generalizability of the results. For data collection, implantable device data was not always available. The PRO survey may also lead to selection bias with more satisfied patients completing the survey than those less satisfied. Additionally, not all patients fully completed the survey at all time points.
Conclusion
AF ablation remains a durable tool for rhythm-control strategies in young adults with AF. In addition to typical outcomes of arrhythmia-free survival, young adults also experience significant improvement in QoL, symptoms and AF related health-care utilization.
What is Known?
Patient-reported outcomes (PRO) help drive better, patient-centered care.
There is a paucity of data related to quality of life (QoL) and arrhythmia-free survival among young adults with atrial fibrillation (AF) after ablation.
What the Study Adds
Using an automated PRO database, 90% of young adults with AF experienced improvement in QoL after 5 years.
Young adult patients experienced lower AF burden and associated healthcare utilization, such as emergency visits and hospitalizations, following AF ablation.
Sources of Funding:
None
Nonstandard Abbreviations and Acronyms
| AF | atrial fibrillation |
| AFL | atrial flutter |
| AFSS | atrial fibrillation severity score |
| AT | atrial tachycardia |
| CAD | coronary artery disease |
| CTI | cavotricuspid isthmus |
| PAC | premature atrial contraction |
| PCI | percutaneous coronary intervention |
| PRO | patient-reported outcome |
| PVI | pulmonary vein isolation |
| QoL | quality of life |
Footnotes
Disclosures: Drs. Hussein and Wazni report receiving consulting honoraria from Biosense Webster. The other authors report no conflicts of interest.
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