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Impact of response to electrical cardioversion before catheter ablation for persistent atrial fibrillation: a

Márton Boga1, Zoltán Salló1, Gábor Orbán1

  • 1Heart and Vascular Center, Semmelweis University, Városmajor Street 68, Budapest 1122, Hungary.

European Heart Journal Open
|July 17, 2025
PubMed

Insights

Maintaining sinus rhythm after electrical cardioversion in persistent atrial fibrillation (AF) patients predicts better outcomes following catheter ablation. Patients who maintained sinus rhythm (SR) showed higher freedom from atrial tachyarrhythmia post-ablation.

Area of Science:

  • Cardiology
  • Electrophysiology

Background:

  • Persistent atrial fibrillation (AF) poses a significant challenge in cardiovascular medicine.
  • Anti-arrhythmic drugs (AADs) and electrical cardioversion (ECV) are common strategies to restore sinus rhythm (SR).
  • Predicting outcomes after catheter ablation in AF patients remains crucial for treatment planning.

Purpose of the Study:

  • To investigate whether maintaining sinus rhythm (SR) after pre-procedural electrical cardioversion (ECV) predicts outcomes in persistent atrial fibrillation (AF) patients undergoing catheter ablation.
  • To compare the efficacy of catheter ablation in patients with sustained SR post-ECV versus those with AF recurrence before ablation.

Main Methods:

  • A cohort of 219 persistent AF patients on AADs undergoing ECV 1-6 months prior to ablation was analyzed.
  • Patients were grouped into ECV-SR (maintained SR) and ECV-AF (AF recurrence) based on pre-ablation rhythm.
  • Propensity score matching created comparable groups (94 patients each) for outcome analysis.
  • Follow-up was conducted for a median of 42 months, assessing freedom from atrial tachyarrhythmia and AF recurrence.

Main Results:

  • Freedom from atrial tachyarrhythmia at 36 months was significantly higher in the ECV-SR group (51.2%) compared to the ECV-AF group (31.4%).
  • Recurrence patterns differed, with persistent AF more common in the ECV-AF group and paroxysmal AF in the ECV-SR group.
  • Freedom from persistent AF at 36 months was also significantly better in the ECV-SR group (84.3%) versus the ECV-AF group (54%).
  • These findings remained consistent across multi-variable adjustments and subgroups, including pulmonary vein isolation (PVI)-only procedures.

Conclusions:

  • Maintaining SR after pre-procedural ECV is a strong predictor of successful catheter ablation outcomes in persistent AF patients.
  • A positive response to ECV may identify patients suitable for a pulmonary vein isolation (PVI)-only ablation strategy.
  • These results highlight the prognostic value of pre-ablation rhythm status for guiding AF management.
Abstract

Keywords:
Catheter ablationElectrical cardioversionPersistent atrial fibrillationPulmonary vein isolationRecurrence

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