Electrical Cardioversion for Persistent Atrial Fibrillation in the Era of Catheter Ablation: A Real-world Observational Study

Abstract

Background: Electrical cardioversion (ECV) is frequently performed to treat persistent atrial fibrillation (AF). Although several large trials have suggested that rate control in AF may be non-inferior to rhythm-based strategies, individual patients may have better outcomes in terms of quality of life if sinus rhythm (SR) is achieved and maintained. This real-world, retrospective, observational study aimed to define the success rate and role of ECV in the management of persistent AF in the era of catheter ablation. Methods: All patients who underwent ECV for symptomatic persistent AF at our institution between January 2014 and August 2019 were analysed. Clinical and echocardiographic baseline characteristics were used to identify independent predictors for AF recurrence at 12 and 24 months using a Cox multivariate model. Results: We identified 1,028 consecutive patients with symptomatic persistent AF, 319 of whom were subsequently excluded from the study because they either spontaneously reverted to SR prior to ECV or declined ECV. We evaluated 701 patients (mean age 71 ± 10.8 years, male 70.2%). Acute success was achieved in 96.8% of patients. SR at 12 and 24 months was seen in 26.6% and 14.3% of patients (p<0.0001), respectively. SR at 12 months was seen in 20.4% of patients with a left atrium (LA) diameter of ≤4 cm and in 6.2% of patients with an LA diameter of >4 cm (p<0.0001). At 24 months, SR was seen in 11.5% of patients with a LA diameter of ≤4 cm and in 2.8% with a diameter of >4 cm (p<0.0001). Predictors of SR at 12 months on univariate analysis were normal left ventricular systolic function and mild left ventricular systolic impairment (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.08–2.45, p=0.021 and OR 0.5, 95% CI 0.24–0.94, p=0.043, respectively). In addition, flecainide and sotalol therapy improved the chances of SR at 12 months (OR 2.87, 95% CI 1.16–7.12, p=0.021 and OR 2.25, 95% CI 0.98–5.05, p=0.049, respectively). Multivariate analysis revealed no further positive predictors for SR maintenance in 24 months. Conclusion: ECV was not an effective long-term strategy for the maintenance of SR.