Abstract 885 Antiarrhythmic drug therapy prior to pulmonary vein isolation does not improve the post-ablation freedom from sustained atrial arrhythmias in patients with persistent atrial fibrillation

In current guidelines pulmonary vein isolation (PVI) is strongly recommended in patients with symptomatic persistent atrial fibrillation (PeAF) after a previous ineffective therapy approach with antiarrhythmic drugs (AAD). First-line ablation of PeAF has only a IIb recommendation in those patients. Hence one can assume, AAD therapy should be favoured as first-line therapie in patients with PeAF before catheter ablation. This raises the question, whether an AAD therapy approach before PVI has a beneficial influence on freedom from post-ablation arrhythmias compared to patients without such a medical therapy.

Objectives
The aim of this study was to evaluate whether the use of AAD prior to PVI can improve the freedom from atrial arrhythmias after PVI in patients with PeAF.

Methods
We performed a retrospective data analysis of a cohort of 644 patients who had untergone PVI using the cryoballoon - with atrial substrate modification (cryo or radiofrequency ablation) if indicated - because of PeAF. Of these patients 298 received AAD (class Ic or class III) prior to PVI. Rate controlling drugs (beta-blocker, calcium channel blocker, digitalis) were allowed in both study groups. A successful ablation was defined as no AF, atrial flutter, or tachycardia lasting more than 30 sec in the absence of antiarrhythmic drugs after a 3-month ECG blanking period and no clinical symptoms of arrhythmia. Statistical analysis was performed using Kaplan-Meier-Estimator.

Results
Patients with and without AAD-therapy prior to PVI show no significant differences in freedom from atrial arrhythmias 8 years after one PVI procedure 48,7% vs. 54,3% (p=0.34). In contrast patients with early PVI (within 1 years since diagnosis, with and without prior AAD therapy) showed significant better freedom from sustained atrial arrhythmias compared to patients with late PVI (> 1 years since diagnosis) (60,9% vs. 46,4%; p<0,001).

Conclusions
The use of AAD before a PVI has no beneficial influence on the freedom from sustained atrial arrhythmias after this PVI procedure. In contrast, early PVI resulted in freedom from atrial arrhythmias more often than delayed catheter ablation. In order to improve the freedom from arrhythmias, symptomatic patients should therefore undergo early PVI instead of investing longer time in AAD therapy.

Clin Res Cardiol (2022). https://doi.org/10.1007/s00392-022-02002-5
Antiarrhythmic drug therapy prior to pulmonary vein isolation does not improve the post-ablation freedom from sustained atrial arrhythmias in patients with persistent atrial fibrillation
P. Kahle¹, J. Hutter¹, S. Zaltsberg¹, A. Berkowitsch¹, E. Waezsada¹, W. Waraich¹, A. Hain¹, J. Sperzel¹, C. W. Hamm², T. Neumann¹, M. Kuniss¹
¹Abteilung für Kardiologie, Kerckhoff Klinik GmbH, Bad Nauheim; ²Medizinische Klinik I - Kardiologie und Angiologie, Universitätsklinikum Gießen und Marburg GmbH, Gießen;
Background In current guidelines pulmonary vein isolation (PVI) is strongly recommended in patients with symptomatic persistent atrial fibrillation (PeAF) after a previous ineffective therapy approach with antiarrhythmic drugs (AAD). First-line ablation of PeAF has only a IIb recommendation in those patients. Hence one can assume, AAD therapy should be favoured as first-line therapie in patients with PeAF before catheter ablation. This raises the question, whether an AAD therapy approach before PVI has a beneficial influence on freedom from post-ablation arrhythmias compared to patients without such a medical therapy. Objectives The aim of this study was to evaluate whether the use of AAD prior to PVI can improve the freedom from atrial arrhythmias after PVI in patients with PeAF. Methods We performed a retrospective data analysis of a cohort of 644 patients who had untergone PVI using the cryoballoon - with atrial substrate modification (cryo or radiofrequency ablation) if indicated - because of PeAF. Of these patients 298 received AAD (class Ic or class III) prior to PVI. Rate controlling drugs (beta-blocker, calcium channel blocker, digitalis) were allowed in both study groups. A successful ablation was defined as no AF, atrial flutter, or tachycardia lasting more than 30 sec in the absence of antiarrhythmic drugs after a 3-month ECG blanking period and no clinical symptoms of arrhythmia. Statistical analysis was performed using Kaplan-Meier-Estimator. Results Patients with and without AAD-therapy prior to PVI show no significant differences in freedom from atrial arrhythmias 8 years after one PVI procedure 48,7% vs. 54,3% (p=0.34). In contrast patients with early PVI (within 1 years since diagnosis, with and without prior AAD therapy) showed significant better freedom from sustained atrial arrhythmias compared to patients with late PVI (> 1 years since diagnosis) (60,9% vs. 46,4%; p<0,001). Conclusions The use of AAD before a PVI has no beneficial influence on the freedom from sustained atrial arrhythmias after this PVI procedure. In contrast, early PVI resulted in freedom from atrial arrhythmias more often than delayed catheter ablation. In order to improve the freedom from arrhythmias, symptomatic patients should therefore undergo early PVI instead of investing longer time in AAD therapy.
https://dgk.org/kongress_programme/jt2022/aP1519.html