Background - With aging societies and increasing incidence of arrhythmias in the elderly, interventional rhythm control strategies are gaining importance. In the last years, catheter ablation has become a standard approach in treating rhythm disorders. Data and experience in treatment of patients over 90 years are still rare.

Methods - All consecutive patients aged over 90 years treated at our institution between 2012 and 2021 were included in this study (n= 45, mean age 91.78 years). Patients undergoing a catheter ablation because of any arrhythmia (AVNRT n=3, accessory pathway n=1, atrial flutter n=7, left atrial tachycardia n=7, atrial fibrillation (AF) n=2, AV-node-ablation n = 2, ventricular premature complex n=1, VT n=2, in total n= 25) as well as an electrical cardioversion (for AF n=14, for AT n=6, in total n = 20) were analyzed concerning efficacy and periprocedural safety. All complications that required intervention, prolonged hospital stay or caused long-time sequelae were classified as major.

Results – In all 25 patients undergoing catheter ablation acute procedure success was achieved. During a mean follow-up of 388 ± 487 days 80% of patients remained in stable sinus rhythm (12/15). 10 Patients were lost to follow-up. In 19/20 patients who underwent cardioversion, sinus rhythm was acutely restored, and maintained in 18/20 during the hospitalization. In one patient, electrical cardioversion failed. Another patient suffered an early recurrence within 12 hours. In both cases, short-term success could be achieved with amiodarone. Unfortunately, 16 patients who received an electrical cardioversion, were lost to follow-up. In 4 remaining patients, during a follow-up of 567 ± 456 days, only one patient was in stable sinus rhythm.

Major complications occurred in 4 patients (8.8%): (1) one death during hospitalization (sepsis due to mesenterial ischemia 5 days after rescue AV-node-ablation). On examination, no causal relationship to the ablation was found. (2) One patient suffered a stroke within 24 hours after ablation of atrial tachycardia despite pre-ablation TEE, uninterrupted NOAC medication and intraprocedural maintained target ACT at 300-350s; fortunately, the patient recovered without long-term consequences. (3) Due to postinterventional high-grade AV-block (not caused by ablation), one patient underwent dual chamber pacemaker implantation. (4) One patient showed symptoms of postoperative delirium which resolved by conservative treatment.
Intraprocedural use of catecholamine was necessary in 4 patients because of sedation-related hypotension or bradycardia. Two patients required admission of antidote (flumazenil, naloxon) due to delayed recovery from sedation. No pericardial tamponade or major groin complication occurred. In two patients suffering from access site hematoma, no intervention or intensified surveillance was needed.

Discussion – Catheter ablation and electrical cardioversion can be performed with low-complication rates at a high-volume-center with adequate preparation. In the future, a growing number of nonagenarians will require safe treatment, thus further research is needed.