Quality of life and healthcare utilisation improvements after atrial fibrillation ablation

Objective

Pulmonary vein isolation (PVI) guided by a standardised CLOSE (contiguous optimised lesions) protocol has been shown to increase clinical success after catheter ablation for paroxysmal atrial fibrillation (PAF). This study analysed healthcare utilisation and quality of life (QOL) outcomes from a large multicentre prospective study, measured association between QOL and atrial fibrillation (AF) burden and identified factors associated with lack of QOL improvement.

Methods

CLOSE-guided ablation was performed in 329 consecutive patients (age 61.4 years, 60.8% male) with drug-refractory PAF in 17 European centres. QOL was measured at baseline and 12 months post-ablation via Atrial Fibrillation Effect on QualiTy of Life Survey (AFEQT) and EuroQoL EQ-5D-5L questionnaires. All-cause and cardiovascular hospitalisations and cardioversions over 12 months pre-ablation and post-ablation were recorded. Rhythm monitoring included weekly and symptom-driven trans-telephonic monitoring, plus ECG and Holter monitoring at 3, 6 and 12 months. AF burden was defined as the percentage of postblanking tracings with an atrial tachyarrhythmia ≥30 s. Continuous measures across multiple time points were analysed using paired t-tests, and associations between various continuous measures were analysed using independent sample t-tests. Each statistical test used two-sided p values with a significance level of 0.05.

Results

Both QOL instruments showed significant 12-month improvements across all domains: AFEQT score increased 25.1–37.5 points and 33.3%–50.8% fewer patients reporting any problem across EuroQoL EQ-5D-5L domains. Overall, AFEQT improvement was highly associated with AF burden (p=0.009 for <10% vs ≥10% burden, p<0.001 for <20% vs ≥20% burden). Cardiovascular hospitalisations were significantly decreased after ablation (42%, p=0.001). Patients without substantial improvement in AFEQT (55/301, 18.2%) had higher AFEQT and CHA₂DS₂-VASc scores at baseline, and higher AF burden following PVI.

Conclusions

QOL improved and healthcare utilisation decreased significantly after ablation with a standardised CLOSE protocol. QOL improvement was significantly associated with impairment at baseline and AF burden after ablation.

Trial registration number

NCT03062046.

P956Improved quality of life and symptomatic atrial fibrillation reduction in patients treated with a standardized ablation index workflow

Background/Introduction

The use of a standardized ‘CLOSE’ ablation workflow for pulmonary vein isolation (PVI), with defined inter-tag distance (ITD) with targeted ablation index (AI) values, has been shown in single centre reports to result in good outcomes. The effect of this approach on patients’ quality of life (QoL) has not been studied.

Purpose

To evaluate the effects of paroxysmal atrial fibrillation (PAF) ablation by the CLOSE workflow on QoL and symptomatic AF reduction in the multicenter VISTAX study.

Methods

329 patients with PAF (61.5% male, 61.3 ± 10.1 year) were treated at 17 European centres by point-by-point radiofrequency ablation using the CLOSE protocol to achieve PVI.  An ITD ≤6mm and AI values of ≥400 on the posterior wall and ≥550 on the anterior wall were targeted. The AI value on the posterior wall was lowered as per investigator discretion in case of safety concerns. Patients were monitored for atrial arrhythmia recurrences via weekly and symptom-activated transtelephonic monitoring (TTM), for 12 months post procedure. Patients completed an Atrial Fibrillation Effect on Quality-of-life (AFEQT) questionnaire at their baseline and 12-month follow up visits.

Results

Majority (83.3% [274/329]) of patients experienced freedom from symptomatic atrial recurrence through 12 months. Of the 70 documented recurrences, 34 (49%) were documented by trans-telephonic monitoring only. All domains captured on the AFEQT questionnaire showed improvement with the overall score improving by 25.7, which exceeded the threshold of clinically meaningful improvement (±5) (Table). Patient reported most improvements in PAF control and symptoms relieved. The overall AFEQT score improvement was seen both in patients with or without documented atrial arrhythmia recurrence, with improvement by 21.5 and 26.8, respectively.

Conclusion

PAF ablation using a standardized CLOSE workflow resulted in consistent improvements in QoL. The improved QoL was observed regardless of atrial arrhythmia recurrence likely reflecting the low residual arrhythmia burden in patients with documented recurrence identified only on TTM.

AFEQT Scores Through 12 Months AFEQT Domain Baseline 12 Months Change from Baseline* Daily Activities 59.2 85.3 26.0 Treatment Concerns 62.2 88.1 26.0 Controlling PAF 50.2 87.8 37.5 Symptoms 63.7 89.0 25.1 Symptoms Relieved 52.0 88.4 36.3 Overall AFEQT Score 61.3 87.2 25.7 *only includes patients who completed both baseline and 12 month AFEQT questionnaire

1242The flexibility, ease of using, and leaving curve of a standardized ablation index workflow for catheter ablation of paroxysmal atrial fibrillation

Background/Introduction

The ‘CLOSE’ protocol, incorporating standardized ablation index (AI) targets in conjunction with defined inter-tag distance (ITD) has been shown to improve the acute and long-term success of pulmonary vein isolation (PVI) when treating paroxysmal atrial fibrillation (PAF). The reproducibility and learning curve for this protocol has not been studied.

Purpose

To assess the acute and long-term efficacy of CLOSE PVI across multiple operators (n = 37) in the 17-centre European study ‘VISTAX’.

Methods

329 patients with PAF (61.8% male, 61.3 ± 10.1 years) underwent PVI according to the CLOSE protocol, with target AI values for each lesion of ≥400 on the posterior wall and ≥550 on the anterior wall, and target ITD of ≤6mm. Each 3-dimensional electroanatomic map was evaluated at a core lab where adherence to each of these criteria was assessed. 281/329 patients (85.1%) fulfilled all standardized workflow requirements and were adjudicated as having their PVI per-protocol (PP). First pass PVI and acute effectiveness (adenosine-proof first pass PVI at 30-minute challenge) were recorded. Clinical effectiveness was assessed as freedom from atrial arrhythmia recurrence through 12 months recorded via transtelephonic monitoring (weekly and symptomatically), in addition to holter and electrocardiogram monitoring during 3,6,12 month follow up visits. Learning curve analysis was evaluated on all investigators.

Results

First pass PVI rates were similar in the overall (86%) and PP cohorts (85%), as was acute effectiveness (82% in both cohorts). Freedom from atrial arrhythmia at 12 months too was identical for both cohorts (79%). Total procedure time and total ablation time decreased by an average 8 minutes and 10 minutes respectively after the first procedure and then showed further steady decreases over the number of ablations performed by the investigator (Figure).  The procedural efficiencies and clinical success were reproducible across different centers. No significant deviations were found from individual sites.

Conclusion

The standardized CLOSE workflow is reproducible across centres, and is ‘forgiving’ without impacting on high efficacy of almost 80%. The learning curve is short, suggesting that the excellent clinical results can be replicated widely and easily.

Abstract Figure. Learning Curves- Procedure & Ablation