Predictors, management, and outcome of cardioversion failure early after atrial fibrillation ablation

Electrical cardioversion (ECV) is frequently required for early atrial fibrillation (AF) recurrence after catheter ablation. However, in some cases, ECV is unsuccessful, and factors associated with long-term rhythm outcomes after failed ECV are unknown. This study aimed to identify possible predictors of ECV failure early after AF ablation and to analyse management and long-term rhythm outcome of these patients.

Between 2010 and 2012, 180 consecutive patients (mean age 63.7 ± 9.4 years, male 53.3%, persistent AF 60%) underwent successful radiofrequency AF ablation but required post-procedural ECV due to early AF recurrence (≤ 7 days). Of these, 120 patients were successful (Group A, n = 120, 66.7%) and 60 failed (Group B, n = 60, 33.3%). ECV failure was associated with diabetes [odds ratio (OR) 2.34, 95% confidence interval (CI) 1.154-4.763; P = 0.01] and lack of beta-blocker medication (OR 2.38, 95% CI 1.005-5.635; P = 0.04). In contrast, there were no significant differences in echocardiographic or procedure-related parameters. Atrial fibrillation recurrence was monitored with sequential 7 days of Holter electrocardiogram for 24 months (on average 10.8 ± 8.8 months) and was documented in 56%, n = 102 in total (Group A: 57%, n = 69 vs. Group B: 55%, n = 33; P = 0.75). Compared with successful ECV, ECV failure shortly after AF ablation had no predictive value on rhythm outcome in the long term (P = 0.98). The necessity of additional linear lesions during catheter ablation [hazard ratio (HR) 2.72, 95% CI 1.47-5.05; P = 0.001], AF duration (HR 1.08, 95% CI 1.04-1.12; P < 0.001), and a prolonged ablation time (HR 3.27, 95% CI 1.53-6.97; P = 0.002) were associated with long-term AF recurrence.

Patients with diabetes and absence of beta-blocker medication are at higher risk for ECV failure. Early post-ablation ECV failure is not associated with long-term rhythm outcome.