Background: The incidence and prevalence of atrial fibrillation (AF) increases with age. Catheter ablation has emerged as an effective treatment option for rhythm control therapy. However, very elderly patients (≥80 years old) have been excluded in landmark clinical trials. Current data regarding the safety and efficacy of catheter ablation in the very elderly is therefore sparse.

Purpose: Due to the growing demand to manage AF in an increasingly ageing population, we investigated the safety and efficacy of catheter ablation in this particular patient population.

Methods: Patients with symptomatic paroxysmal, persistent and long-standing persistent AF aged ≥80 years undergoing catheter ablation, including first and re-ablation procedures in a single centre, were analysed retrospectively. Catheter ablation involved pulmonary vein isolation (PVI) using radiofrequency, cryoballoon and pulsed field ablation as energy sources. Re-ablation procedures included re-PVI and consecutive atrial tachycardia ablation including atrial lines and/or ablation of complex fractionated atrial electrograms (CFAE) in persistent AF. Endpoints included acute success (complete isolation of pulmonary veins and/or non-inducibility in the case of atrial tachycardia), complications and early arrhythmia-recurrence.

Results: A total of 126 patients (mean age 82.2 ± 1.9 years, mean CHA₂DS₂-VASc-Score 4.2 ± 1.1, mean left ventricular ejection fraction 57± 7.4%) were included from January 2021 until January 2022. Seventy cases (55.6%) involved PVI as an index procedure (radiofrequency 54.3%, n=38/70, cryoballoon 40%, n=28/70, pulsed field ablation 5.7%, n=4/70). Fifty-six procedures (44.4%) involved re-ablation procedures (Re-PVI 57.1%, n=32/56, linear lesions 65.8%, n=25/38, atrial tachycardia ablation 26.8%, n=15/56 and ablation of CFAE 28.6%, n=16/56). Acute success was achieved in 125/126 patients (99.2%). Major complications included stroke (n=1/126, 0.8%), pericardial tamponade (n=2/126, 1.6%) and bradycardia with subsequent pacemaker implantation (n=3/125, 2.4%). Other complications included pneumonia (2/126, 1.6%), urinary tract infection (3/126, 2.4%), renal failure (3/126, 2.4%) and phrenic nerve palsy (1/126, 0.8%). No further major complications were documented. In 18/126 patients (14.3%) early arrhythmia-recurrence occurred during the 90-day blanking period (n=8/18, 44.4% after index procedures and n=10/18, 55.6% after re-ablation).

Conclusions: Catheter ablation for atrial fibrillation in the very elderly shows favourable acute success and low complication rates. Long term success of catheter ablation and superiority to rate control in this patient population is unknown and requires investigation in the future.