Cardioversion versus ablation versus 'pace and ablate' for persistent atrial fibrillation in older patients

Area of Science:

• Cardiology
• Electrophysiology
• Geriatrics

Background:

• Persistent atrial fibrillation (AF) significantly impacts quality of life and exercise capacity in older adults.
• Current treatment options for persistent AF in patients aged 65 and older include AF ablation, permanent pacemaker (PPM) with atrioventricular node ablation (AVNA), and direct current cardioversion (DCCV).

Purpose of the Study:

• To compare the efficacy of AF ablation, PPM with AVNA, and DCCV for treating persistent AF in patients aged 65 years and older.
• To evaluate AF recurrence, symptom burden, and cardiopulmonary function following these interventions.

Main Methods:

• Seventy-seven patients with persistent AF were randomized to AF ablation + amiodarone, PPM with AVNA, or DCCV + amiodarone.
• Primary endpoint was persistent AF recurrence detected by implanted monitors or PPM over 12 months.
• Cardiopulmonary exercise testing (CPET) and symptom questionnaires were used to assess outcomes.

Main Results:

• AF ablation + amiodarone showed a lower AF burden at 12 months compared to DCCV + amiodarone (17.0% vs. 61.7%, p<0.0001).
• There was a non-significant trend towards reduced AF recurrence with ablation compared to DCCV (28% vs. 60%, HR 0.559).
• All treatment groups demonstrated improved Modified European Heart Rhythm Association (mEHRA) symptom scores and increased VO2 peak with sinus rhythm restoration.

Conclusions:

• In older patients with persistent AF, AF ablation combined with amiodarone leads to a reduced AF burden compared to DCCV with amiodarone.
• While not statistically significant, AF ablation showed a trend towards lower recurrence rates.
• All evaluated therapies improved patient symptoms and exercise capacity, although DCCV restored sinus rhythm in less than 50% of patients.