Early rhythm-control ablation: insight from the CHARISMA registry

Early ablation therapy (<1 year after the first arrhythmic event) significantly reduced the risk of atrial fibrillation (AF) recurrence compared with delayed ablation [1]. Besides the timing of ablation, hypertension was an important predictor of recurrence.

An early rhythm-control therapy in patients with AF has been associated with improved cardiovascular outcomes and a lower rate of recurrences, for example in the recent EAST-AFNET 4 trial [2,3]. Dr Luca Segreti (Azienda Ospedaliero, Universitaria Pisana, Italy) and colleagues aimed to investigate the importance of timing of ablation in preventing AF recurrences.

The study enrolled 153 consecutive patients from the CHARISMA registry (NCT03793998), who underwent AF ablation at 8 Italian centres. Ablations were guided by a novel radiofrequency ablation catheter with local impedance (LI)-sensing capability through a dedicated algorithm. Patients were grouped as early treated (n=80) if the procedure was performed within 1 year after the first AF episode, and as delayed treated (n=73) if admitted for ablation after more than 1 year. The study’s endpoint was pulmonary vein isolation (PVI) as assessed by entrance and exit block. Long-term endpoints were AF and atrial tachycardia (AT) recurrences. Follow-up took place at 3, 6, and 12 months post-ablation.

Patient and arrhythmia characteristics were similar between the groups. According to current ESC AF guideline classification, 123 (80.4%) of the participants met Class I indications, 23 (15%) met Class IIa indications, and 7 (4.6%) Class IIb indications. The mean time to ablation procedure from the first arrhythmic episode was 202 days in early treated patients and 1,945 in patients receiving delayed treatment. No differences were found between AF type in terms of ablation strategy. At the end of the procedures, pulmonary veins had been successfully isolated in all participants.

Mean follow-up period was 366 days, during which 18 patients (11.8%) suffered an AF/AT recurrence after the 90-day blanking period. Recurrences occurred mostly in the delayed treatment group compared with the early treatment group (17.8% vs 6.3%, respectively; P=0.042) and the time to AT/AF recurrence was longer in the early treatment group (HR 0.2876; 95% CI 0.10–0.80; P=0.0181). Multivariate logistic analysis adjusted for baseline confounders showed that only hypertension was independently associated with recurrences (HR 4.66; 95% CI 1.5–14.48; P=0.0081). An early rhythm-control therapy was associated with a low risk of recurrences beyond the hypertension risk factor, ranging from 2% (no hypertension and an early ablation therapy) to 30.3% (with hypertension and a delayed procedure).

Dr Segreti concluded that patients with AF without common risk factors undergoing early ablation have a lower risk of recurrences compared with delayed treatment and that LI-guided ablation of AF is a safe and efficacious procedure.

1. 
   
   1. Segreti L. Early rhythm control ablation therapy in preventing AF recurrences: insight from the CHARISMA registry. EHRA 2021 Congress, 23-25 April.
   2. Lycke M, et al. Europace 2020;euaa383.
   3. Kirchhof P, et al. N Engl J Med 2020;383(14):1305-1316.

 

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Posted on 16 June, 202122 June, 2021