Impact of sinus rhythm maintenance using catheter ablation on
clinical hard endpoints
A number of large propensity-matched registry-based cohort
studies4-8 have shown that catheter ablation of AF is
significantly associated with a lower incidence of stroke, heart
failure, and death compared with medical therapy alone. However, most of
those registry-based studies lacked information on AF recurrence after
catheter ablation. The impact of sinus rhythm maintenance after catheter
ablation on clinical outcomes has been investigated in only a few
retrospective studies and our results were generally in accordance with
these previous reports.
Lin et al.20 studied patients with AF whose
CHA2DS2-VASc scores were ≥1 and who
underwent catheter ablation in Taiwan. In that single-center study,
freedom from AF after ablation was found to be a predictor of a lower
incidence of major adverse cardiovascular events, including total
vascular events (ischemic stroke, TIA, acute coronary artery events, and
peripheral vascular events or pulmonary embolism) and death.
Unfortunately, the number of study patients was somewhat small (118 in
the nonrecurrence group and 56 in the recurrence group).
Hunter et al.21 tested 1273 patients with AF in a
multicenter study in the UK and Australia and showed that freedom from
AF after ablation was a predictor of stroke free survival. Ghanbari et
al.22 studied 3058 patients with AF from a
single-center registry in Michigan and found that sinus rhythm
maintenance after catheter ablation of AF was independently associated
with a lower risk of cardiac mortality, although the authors found no
significant reduction in cerebrovascular events or mortality. These two
studies are relatively old, and the recruited patients underwent
catheter ablation before 2011, thereby predominantly using warfarin
instead of DOACs. To identify the effect of sinus rhythm maintenance
more clearly, patients taking DOACs might be more suitable than those
taking warfarin given that DOACs are associated with fewer adverse
events.23-26 All of the patients in our study
underwent AF ablation after 2011, and DOACs were predominantly
prescribed in 78.4% of the patients. Our study is the first to
demonstrate the favorable effect of sinus rhythm maintenance after AF
ablation on hard endpoints from a large multicenter cohort in the DOAC
era. Interestingly, the reduction in the primary endpoint by sinus
rhythm maintenance per se was considerable (HR 0.57) and was
comparable to that of the AFFIRM study (HR 0.54).18,
19