Efficacy of Radiofrequency Catheter Pulmonary Vein Isolation with Preoperative Electrical Cardioversion in Patients with Persistent Atrial Fibrillation

Atrial fibrillation (AF) is the most common form of cardiac arrhythmia in clinical practice treated with both pharmacological and surgical methods. Since the use of antiarrhythmic drugs does not always effectively control the heart rhythm and imposes a risk of developing proarrhythmias and conduction disturbances, radiofrequency ablation of the pulmonary vein ostia has become a recognized treatment for patients with symptomatic AF. Recurrences after catheter ablation (CA) in patients with persistent and long-standing persistent AF are significantly more common than in paroxysmal AF. In clinical practice, it is important to accurately predict the long-term outcomes of CA in patients with persistent AF to determine further treatment tactics. There is evidence that restoration of sinus rhythm before surgical treatment reduces the risk of recurrence in patients with persistent AF; however, these associations have not been adequately studied.

In patients with persistent, especially long-standing persistent AF, the degree of arrhythmogenic atrial remodeling can vary widely. Predicting the effectiveness of CA and adjusting the extent of the procedure requires a detailed characterization of the arrhythmogenic substrate in the left atrium (LA), which can be achieved through detailed mapping of areas with fibrotic changes and low-amplitude activity. Therefore, the aim of this review is to summarize the reports about the impact of prior electrical cardioversion before CA in patients with AF on the long-term outcomes of the catheter-based treatment and a possibility of achieving structural and functional reverse LA remodeling. This review may be useful for practicing interventional arrhythmologists and cardiologists engaged in the surgical and medical treatment of patients with persistent AF.

1. Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG et al. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2024;26(4):euae043. DOI: 10.1093/europace/euae043

2. Padfield GJ, Steinberg C, Swampillai J, Qian H, Connolly SJ, Dorian P et al. Progression of paroxysmal to persistent atrial fibrillation: 10-year follow-up in the Canadian Registry of Atrial Fibrillation. Heart Rhythm. 2017;14(6):801–7. DOI: 10.1016/j.hrthm.2017.01.038

3. Hermans BJM, Weberndörfer V, Bijvoet GP, Chaldoupi S-M, Linz D. New concepts in atrial fibrillation pathophysiology. Herzschrittmachertherapie + Elektrophysiologie. 2022;33(4):362–6. DOI: 10.1007/s00399-022-00897-1

4. Huang T, Yap L, Chen C, Lin H, Lin S, Li Y. Long‐Term Statin Use Is Associated With Reduced Rates of Adverse Events in Patients With Newly Diagnosed Atrial Fibrillation. Journal of the American Heart Association. 2024;13(24):e035827. DOI: 10.1161/JAHA.124.035827

5. Charitakis E, Dragioti E, Stratinaki M, Korela D, Tzeis S, Almroth H et al. Predictors of recurrence after catheter ablation and electrical cardioversion of atrial fibrillation: an umbrella review of meta-analyses. EP Europace. 2023;25(1):40–8. DOI: 10.1093/europace/euac143

6. Khan IA. Atrial stunning: basics and clinical considerations. International Journal of Cardiology. 2003;92(2–3):113–28. DOI: 10.1016/ S0167-5273(03)00107-4

7. Gromyko T.Yu., Saiganov S.A. Remodeling of the Left Atrium and the Possibility of Predicting Recurrences of Atrial Fibrillation in Various Variants of Sinus Rhythm Restoration. Cardiac Arrhythmias. 2023;2(4):29–42. DOI: 10.17816/cardar120108

8. Hoit BD. Left Atrial Remodeling: More Than Just Left Atrial Enlargement. Circulation: Cardiovascular Imaging. 2017;10(2):e006036. DOI: 10.1161/CIRCIMAGING.117.006036

9. Roka A, Burright I. Remodeling in Persistent Atrial Fibrillation: Pathophysiology and Therapeutic Targets – A Systematic Review. Physiologia. 2023;3(1):43–72. DOI: 10.3390/physiologia3010004

10. Manning WJ, Leeman DE, Gotch PJ, Come PC. Pulsed Doppler evaluation of atrial mechanical function after electrical cardioversion of atrial fibrillation. Journal of the American College of Cardiology. 1989;13(3):617–23. DOI: 10.1016/0735-1097(89)90602-5

11. Siebermair J, Suksaranjit P, McGann CJ, Peterson KA, Kheirkhahan M, Baher AA et al. Atrial fibrosis in non–atrial fibrillation individuals and prediction of atrial fibrillation by use of late gadolinium enhancement magnetic resonance imaging. Journal of Cardiovascular Electrophysiology. 2019;30(4):550–6. DOI: 10.1111/jce.13846

12. Mouselimis D, Tsarouchas AS, Pagourelias ED, Bakogiannis C, Theofilogiannakos EK, Loutradis C et al. Left atrial strain, intervendor variability, and atrial fibrillation recurrence after catheter ablation: A systematic review and meta-analysis. Hellenic Journal of Cardiology. 2020;61(3):154–64. DOI: 10.1016/j.hjc.2020.04.008

13. B Schnabel R, Pecen L, Engler D, Lucerna M, Sellal JM, Ojeda FM et al. Atrial fibrillation patterns are associated with arrhythmia progression and clinical outcomes. Heart. 2018;104(19):1608–14. DOI: 10.1136/heartjnl-2017-312569

14. de Vos CB, Pisters R, Nieuwlaat R, Prins MH, Tieleman RG, Coelen R-JS et al. Progression from paroxysmal to persistent atrial fibrillation clinical correlates and prognosis. Journal of the American College of Cardiology. 2010;55(8):725–31. DOI: 10.1016/j.jacc.2009.11.040

15. Frick M, Frykman V, Jensen‐Urstad M, Östergren J. Factors predicting success rate and recurrence of atrial fibrillation after first electrical cardioversion in patients with persistent atrial fibrillation. Clinical Cardiology. 2001;24(3):238–44. DOI: 10.1002/clc.4960240313

16. Kozhenov A.T., Azizov S.N., Khuziakhmetov R.D., Musaev O.G., Arutyunyan V.B. Prevention of early recurrences of atrial fibrillation in patients after ablation due to persistent atrial fibrillation. Bulletin of Pirogov National Medical & Surgical Center. 2021;16(3):68–72. DOI: 10.25881/20728255_2021_16_3_68

17. Heijman J, Luermans JGLM, Linz D, Van Gelder IC, Crijns HJGM. Risk Factors for Atrial Fibrillation Progression. Cardiac Electrophysiology Clinics. 2021;13(1):201–9. DOI: 10.1016/j.ccep.2020.10.011

18. Blum S, Meyre P, Aeschbacher S, Berger S, Auberson C, Briel M et al. Incidence and predictors of atrial fibrillation progression: A systematic review and meta-analysis. Heart Rhythm. 2019;16(4):502–10. DOI: 10.1016/j.hrthm.2018.10.022

19. Ogawa H, An Y, Ikeda S, Aono Y, Doi K, Ishii M et al. Progression From Paroxysmal to Sustained Atrial Fibrillation Is Associated With Increased Adverse Events. Stroke. 2018;49(10):2301–8. DOI: 10.1161/STROKEAHA.118.021396

20. Blum S, Aeschbacher S, Meyre P, Zwimpfer L, Reichlin T, Beer JH et al. Incidence and Predictors of Atrial Fibrillation Progression. Journal of the American Heart Association. 2019;8(20):e012554. DOI: 10.1161/JAHA.119.012554

21. Dudink EAMP, Erküner Ö, Berg J, Nieuwlaat R, De Vos CB, Weijs B et al. The influence of progression of atrial fibrillation on quality of life: a report from the Euro Heart Survey. EP Europace. 2018;20(6):929–34. DOI: 10.1093/europace/eux217

22. Liżewska-Springer A, Dąbrowska-Kugacka A, Lewicka E, Drelich Ł, Królak T, Raczak G. Echocardiographic predictors of atrial fibrillation recurrence after catheter ablation: A literature review. Cardiology Journal. 2020;27(6):848–56. DOI: 10.5603/CJ.a2018.0067

23. Marchese P, Bursi F, Delle Donne G, Malavasi V, Casali E, Barbieri A et al. Indexed left atrial volume predicts the recurrence of non-valvular atrial fibrillation after successful cardioversion. European Journal of Echocardiography. 2011;12(3):214–21. DOI: 10.1093/ejechocard/jeq176

24. Zagatina A, Ciampi Q, Peteiro JV, Kalinina E, Begidova I, Padang R et al. Left atrial function during exercise stress echocardiography as a sign of paroxysmal/persistent atrial fibrillation. Cardiovascular Ultrasound. 2024;22(1):13. DOI: 10.1186/s12947-024-00332-0

25. Zagatina A, Rivadeneira Ruiz M, Ciampi Q, Wierzbowska-Drabik K, Kasprzak J, Kalinina E et al. Rest and Stress Left Atrial Dysfunction in Patients with Atrial Fibrillation. Journal of Clinical Medicine. 2023;12(18):5893. DOI: 10.3390/jcm12185893

26. Moskovskikh T.V., Smorgon A.V., Archakov E.A., Usenkov S.Yu., Batalov R.E., Popov S.V. Effect of catheter ablation for atrial fibrillation on left and right atrial function. Russian Journal of Cardiology. 2022;27(7):99–104. DOI: 10.15829/1560-4071-2022-5087

27. Verma A, Wazni OM, Marrouche NF, Martin DO, Kilicaslan F, Minor S et al. Pre-existent left atrial scarring in patients undergoing pulmonary vein antrum isolation: an independent predictor of procedural failure. Journal of the American College of Cardiology. 2005;45(2):285–92. DOI: 10.1016/j.jacc.2004.10.035

28. Liu H-T, Yang C-H, Lee H-L, Chang P-C, Wo H-T, Wen M-S et al. Clinical Outcomes of low-voltage area-guided left atrial linear ablation for non-paroxysmal atrial fibrillation patients. PLOS ONE. 2021;16(12):e0260834. DOI: 10.1371/journal.pone.0260834

29. Mohanty S, Mohanty P, Di Biase L, Trivedi C, Morris EH, Gianni C et al. Long-term follow-up of patients with paroxysmal atrial fibrillation and severe left atrial scarring: comparison between pulmonary vein antrum isolation only or pulmonary vein isolation combined with either scar homogenization or trigger ablation. EP Europace. 2017;19(11):1790–7. DOI: 10.1093/europace/euw338

30. Mannion J, Galvin J, Boles U. Left atrial scar identification and quantification in sinus rhythm and atrial fibrillation. Journal of Arrhythmia. 2020;36(6):967–73. DOI: 10.1002/joa3.12421

31. Andrés Lahuerta A, Roberto C, Saiz FJ, Cano Ó, Martínez-Mateu L, Alonso P et al. Atrial low voltage areas: A comparison between atrial fibrillation and sinus rhythm. Cardiology Journal. 2022;29(2):252–62. DOI: 10.5603/CJ.a2021.0125

32. Mannion J, Hong K, Lennon S-J, Kenny A, Galvin J, O’Brien J et al. Comparing Left Atrial Low Voltage Areas in Sinus Rhythm and Atrial Fibrillation Using Novel Automated Voltage Analysis: A Pilot Study. Cardiology Research. 2023;14(4):268–78. DOI: 10.14740/cr1503

33. Bassiouny M, Saliba W, Hussein A, Rickard J, Diab M, Aman W et al. Randomized Study of Persistent Atrial Fibrillation Ablation: Ablate in Sinus Rhythm Versus Ablate Complex-Fractionated Atrial Electrograms in Atrial Fibrillation. Circulation: Arrhythmia and Electrophysiology. 2016;9(2):e003596. DOI: 10.1161/CIRCEP.115.003596

34. Kulikov A.A., Sapel’nikov O.V., Uskach T.M., Cherkashin D.I., Shlevkov N.B., Grishin I.R. et al. Efficiency of pulmonary vein isolation and ablation of foci of rotary activity in patients with persistent atrial fibrillation. Eurasian heart journal. 2021;2(35):70–6. DOI: 10.38109/2225-1685-2021-2-70-76

35. Balk EM, Garlitski AC, Alsheikh‐Ali AA, Terasawa T, Chung M, Ip S. Predictors of Atrial Fibrillation Recurrence After Radiofrequency Catheter Ablation: A Systematic Review. Journal of Cardiovascular Electrophysiology. 2010;21(11):1208–16. DOI: 10.1111/j.1540-8167.2010.01798.x

36. Virk SA, Bennett RG, Trivic I, Campbell T, Kumar S. Contact Force and Ablation Index. Cardiac Electrophysiology Clinics. 2019;11(3):473–9. DOI: 10.1016/j.ccep.2019.05.007

37. Mikhaylov E.N., Gasimova N.Z., Ayvazyan S.A., Artyukhina E.A., Gromyko G.A., Ivanitskii E.A. et al. Factors associated with the efficacy of atrial fibrillation radiofrequency catheter ablation: opinion of the specialists who use the “ablation index” module. Journal of Arrhythmology. 2020;27(3):9–24. DOI: 10.35336/VA-2020-3-9-24

38. Choi SH, Yu HT, Kim D, Park J-W, Kim T-H, Uhm J-S et al. Late recurrence of atrial fibrillation 5 years after catheter ablation: predictors and outcome. Europace. 2023;25(5):euad113. DOI: 10.1093/europace/euad113

39. Ecker V, Knoery C, Rushworth G, Rudd I, Ortner A, Begley D et al. A review of factors associated with maintenance of sinus rhythm after elective electrical cardioversion for atrial fibrillation. Clinical Cardiology. 2018;41(6):862–70. DOI: 10.1002/clc.22931

40. Jaakkola S, Lip GYH, Biancari F, Nuotio I, Hartikainen JEK, Ylitalo A et al. Predicting Unsuccessful Electrical Cardioversion for Acute Atrial Fibrillation (from the AF-CVS Score). The American Journal of Cardiology. 2017;119(5):749–52. DOI: 10.1016/j.amjcard.2016.11.026

41. Son NKL, Park J-W, Kim M, Yang SY, Yu HT, Kim T-H et al. Efficacy and Safety of Outpatient Clinic-based Elective External Electrical Cardioversion in Patients with Atrial Fibrillation. Korean Circulation Journal. 2020;50(6):511–23. DOI: 10.4070/kcj.2019.0310

42. Kamada H, Mori K, Ueda N, Wakamiya A, Nakajima K, Kamakura T et al. Impact of Pre-Ablation Direct Current Cardioversion for Persistent Atrial Fibrillation to Predict Recurrence of Atrial Fibrillation after Catheter Ablation. International Heart Journal. 2022;63(5):828–36. DOI: 10.1536/ihj.22-135

43. Hanaki Y, Machino‐Ohtsuka T, Aonuma K, Komatsu Y, Machino T, Yamasaki H et al. Preprocedural restoration of sinus rhythm and left atrial strain predict outcomes of catheter ablation for long‐standing persistent atrial fibrillation. Journal of Cardiovascular Electrophysiology. 2020;31(7):1709–18. DOI: 10.1111/jce.14540

44. Wang D, Zhang F, Wang A. Impact of Additional Transthoracic Electrical Cardioversion on Cardiac Function and Atrial Fibrillation Recurrence in Patients with Persistent Atrial Fibrillation Who Underwent Radiofrequency Catheter Ablation. Cardiology Research and Practice. 2016;2016:1–4. DOI: 10.1155/2016/4139596

45. Kanthasamy V, Schilling R, Zongo O, Khan K, Earley M, Monk V et al. Feasibility of double-blinded, placebo-controlled interventional study for assessing catheter ablation efficacy in persistent atrial fibrillation: Insights from the ORBITA AF feasibility study. American Heart Journal. 2024;269:56–71. DOI: 10.1016/j.ahj.2023.12.007