Europace (2023) 25, 676–681 EHRA SURVEY https://doi.org/10.1093/europace/euac194 Rhythm monitoring, success definition, recurrence, and anticoagulation after atrial fibrillation ablation: results from an EHRA survey Ana Carolina Schwab 1*, Ante Anic 2, Michal M. Farkowski 3, Jose Guerra 4 , Konstantinos E. Iliodromitis 5, Kristine Jubele 6,7, Rui Providencia 8,9, Julian K.R. Chun 10, and Serge Boveda 11,12,13 1 Department of Cardiology, Helios Frankenwaldklinik Kronach, Kronach, Germany; 2Department for Cardiovascular Diseases, University Hospital Center Split, Split, Croatia; 3 II Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland; 4Department of Cardiology, Hospital de la Santa Creu I Sant Pau, IIB SANT PAU, CIBERCV, Universitat Autonòma de Barcelona, Barcelona, Spain; 5Evangelical Hospital Hagen-Haspe, Clinic for Cardiology and Electrophysiology, Hagen, Germany; 6Arrhythmia Department, P. Stradins Clinical University Hospital, Riga, Latvia; 7Arrhythmia Department, Riga Stradins University Riga, Latvia; 8St Bartholomew’s Hospital, Barts Heart Centre, Barts Health NHS Trust, London, UK; 9Institute of Health Informatics, University College of London, London, UK; 10CCB, Cardiology, Med. Klinik III, Markuskrankenhaus Frankfurt, Germany; 11 Heart Rhythm Department, Clinique Pasteur, 31076 Toulouse, France; 12Universitair Ziekenhuis Brussel - VUB, Heart Rhythm Management Centre, Brussels, Belgium; and 13Paris Cardiovascular Research Center, INSERM U970, 75908 Paris Cedex 15, France Received 23 September 2022; accepted after revision 5 October 2022; online publish-ahead-of-print 14 November 2022 Abstract Atrial fibrillation (AF) is a major challenge for the healthcare field. Pulmonary vein isolation is the most effective treatment for the maintenance of sinus rhythm. However, clinical endpoints for the procedure vary significantly among studies. There is no consensus on the definition of recurrence and no clear roadmap on how to deal with recurrences after a failed ablation. The purpose of this study was to perform a survey in order to show how clinicians currently approach this knowledge gap. An online survey, supported by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, was con­ ducted between 1 April 2022 and 8 May 2022. An anonymous questionnaire was disseminated via social media and EHRA newsletters, for clinicians to complete. This consisted of 18 multiple-choice questions regarding rhythm monitoring, definitions of a successful ablation, clinical practices after a failed AF ablation, and the continuance of anticoagulation. A total of 107 replies were collected across Europe. Most respondents (82%) perform routine monitoring for AF recurrences after ablation, with 51% of them preferring a long-term monitoring strategy. Cost was reported to have an impact on the choice of monitoring strategy. Self-screening was recommended by most (71%) of the respondents. The combination of absence of symptoms and recorded AF was the definition of success for most (83%) of the respondents. Cessation of anticoagulation after ablation was an option mostly for patients with paroxysmal AF and a low CHA2DS2-VASc score. The majority of phy­ sicians perform routine monitoring after AF ablation. For most physicians, the combination of the absence of symptoms and electrocardiographic endpoints defines a successful result after AF ablation. -Keywords -------------------------------------------------------------------------------------------------------------------------------------------------------------- Catheter ablation • Rhythm monitoring • Anticoagulation • EHRA survey • Recurrence * Corresponding author. E-mail address: carolinaschwab@gmail.com © The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Atrial fibrillation ablation: an EHRA survey 677 What’s new? Results Sociodemographic profile of respondents • This is the first comprehensive, multi-national survey on real-world A total of 107 respondents completed the survey; 23% of the respon­ practices after AF ablation in regard to recurrences and monitoring. dents were aged 30–39, 32% aged 40–49, 29% aged 50–59, and 15% • More than 80% of physicians perform routine monitoring after AF were >60 years. Participant physicians represented 21 members of ablation. the ESC, 5% were from countries represented by affiliated societies, and 82% were male. The respondents identified themselves as senior • For most physicians, the combination of the absence of symptoms EPs (37%), heads of an EP laboratory/department (38%), EP fellows and electrocardiographic endpoints defines a successful result (9%), and junior EP (14%). after AF ablation. Rhythm monitoring Routine monitoring of recurrences after AF ablation is performed by Introduction 82% of the respondents. Approximately, half (51%) of the respondents Atrial fibrillation (AF) is the most common arrhythmia in daily clinical think that short-term monitoring strategies (electrocardiogram, practice. Its estimated prevalence was 59.7 million in 2019, which had 24–48 h Holter monitoring) are not enough to monitor recurrences almost doubled since 1990.1 A recent publication suggests that the dir­ after AF ablation, and advocate for longer monitoring investigations. ect costs of AF to the UK National Health Service in 2030 will be be­ Smartphones/wearables are routinely used by 37% of the responders tween £2.3 billion and £5.6 billion, mainly driven by admissions.2 as a long-term monitoring strategy (Figure 1). External loop recorder Pulmonary vein isolation (PVI) is the most effective treatment for or 7-day Holter was used routinely by 29% of the respondents. The maintenance of sinus rhythm.3 However, success rates and clinical end­ greatest limitation of long-term monitoring strategies as shown in points for PVI vary significantly among studies.4 This is in part due to the Figures 1 and 2 are costs, which abrogated the adoption of smart­ diverse definitions of recurrence after PVI, as well as the different mon­ phones/wearables and implantable loop recorders for 37 and 47% of itoring methods implemented to document asymptomatic recur­ the respondents, respectively. rences.5,6 Even the classic definition of an AF episode recommended As many as 71% of the respondents (57/80) routinely instruct the pa­ by the European Society of Cardiology (ESC) AF 2020 guidelines tients to perform frequent self-screening following the methods shown (30 s)3 has not enough data supporting it because a 30 s recording in Figure 3. Rhythm monitoring with a pulse oximeter was not recom­ does not always predict clinically meaningful AF patterns.7 mended by any of the respondents. It is known that the success rate of catheter ablation varies significantly depending on the type and duration of AF,8 electrical and structural re­ Success definition modelling of the left atrium and the expertise of a cardiac electrophysi­ A composite endpoint (both the absence of symptoms and of recorded ologist (EP),9 the diagnosis-to-ablation time,10 as well as the screening AF) was reported as the success endpoint for 83% of the respondents. tools and duration of the screening afterwards.11 This may result in a suc­ However, it was difficult to find a consensus about the minimal duration cess rate variation between 50 and 80%, over 1–2 years of follow up.12 that should be considered for an AF recurrence. The absence of re­ The AF 2020 ESC guidelines point out that the optimal procedural corded AF was defined as ‘no significant AF burden’ for 31% of the outcome measure, the definition of success after ablation, and the group, while 24% defended the idea of no recurrence if not longer threshold of AF burden that requires anticoagulation are important evi­ than 30 s, and 28% required no recorded AF at all, independently dence gaps.3 We have performed a survey to better understand how from burden or duration. The endpoint of a successful AF ablation, clinicians currently deal with these areas of uncertainty. for 15% of the respondents, was rendering the patient asymptomatic. The absence of recorded AF, independent of symptoms, was stated as success definition by 1% of treating physicians. Methods When treating the recurrence, patients with persistent AF should re­ ceive more intensive treatment compared with those patients with par­ Study methodology oxysmal AF, in the opinion of the respondents. Figure 4 shows the A questionnaire was developed by the European Heart Rhythm Association physician preference for AF management following failed AF ablation. (EHRA) Scientific Initiatives Committee and distributed through the Survey Monkey Platform. The questionnaire was anonymous and complied with the Pulmonary vein isolation only was therapy of choice for paroxysmal European General Data Protection Regulation 2016/679. The questionnaire AF recurrence (P = 0.01). Substrate modification was therapy of choice consisted of 18 multiple-choice questions regarding rhythm monitoring, suc­ for persistent AF recurrence (P = 0.03). cess definition, clinical practice after failed ablation, and anticoagulation. The Following failed AF ablation, 21% of physicians change their strategy full questionnaire is provided in the Supplementary material online, Appendix. to rate control if AF is persistent, and only 7% change to rate control if AF is paroxysmal (P = 0.02). Study duration and distribution The survey was conducted online between 1 April 2022 and 8 May 2022, Anticoagulation and left atrial appendance and was promoted via social media (Facebook, Twitter, and LinkedIn) and EHRA newsletters, as well as national working groups newsletters. closure device The respondents answered whether oral anticoagulants (OACs) should be interrupted after successful AF ablation and when, if so. Statistical analysis The questionnaire proposed different scenarios depending on the AF Categorical variables are expressed as numbers and percentages. Pearson’s type (paroxysmal or persistent), and the CHA2DS2-VASc score (0, 1, χ2 test is used to compare groups. Statistics are obtained using the IBM or >2 for men, or 1, 2, or >3 for women). The available options were: Statistical Product and Service Solutions Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA) is used. A P-value that is <0.05 is con­ (1) Interruption of OAC 2 months after successful PVI, sidered statistically significant. (2) Interruption of OAC as per local protocol, 678 A.C. Schwab et al. 40.0% 37% 37% 35.0% 30.0% 25.0% 20.0% 16% 15.0% 14% 10% 9% 10.0% 5.0% 0.0% Yes No - I see no No - costs are No - lack of No - lack of No answer benefits not usually familiarity trust covered Figure 1 Use of smartphones/wearables for recurrence monitoring after AF ablation (with more than one negative answer allowed). 50.0% 47% 45.0% 40.0% 35.0% 30.0% 25.0% 21.4% 20.0% 12.8% 15.4% 15.0% 10.0% 8.5% 2.6% 5.0% 0.0% Yes No - I see no No - fear of No - lack of No - costs are not No answer benefits implant personnel covered complications Figure 2 Use of implantable loop recorders for recurrence monitoring after AF ablation (with more than one negative answer allowed). (3) Interruption of OAC based on the obtained cardiac implantable CHA2DS2-VASc score, 47% prescribe OAC only for a period of 2 electronic device (CIED) interrogation, months, and 8% do not prescribe any OAC at all. (4) Interruption of OAC based on information obtained from wear­ ables or smartphones, and (5) No interruption of OAC. Discussion The groups were divided according to whether there was persistent This survey allows a better understanding of the current clinical practice or paroxysmal AF, and according to the CHA2DS2-VASc score. after AF ablation. The key findings are that: The interruption of OAC after AF ablation was declared more fre­ quent in patients with paroxysmal AF and a low CHA2DS2-VASc score, as shown in Table 1. • The majority of respondents perform routine monitoring after AF ablation, with more than half preferring a long-term monitoring Regarding the subgroup of patients with previous left atrial append­ strategy. age closure (LAAC), 14% of respondents do not perform AF ablation in this subset of patients. For the rest of physicians who perform AF ab­ • The cost of long-term monitoring was the main reason for not lation in patients with LAAC, 19% prescribe OAC regardless of the using it. Atrial fibrillation ablation: an EHRA survey 679 40.00% 35% 34% 35.00% 31% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0% 0.00% Self-palpation of the Digital manometer Pulse oximeter Smart watch radial artery Figure 3 Self-screening instructions to assess heart rate of patients. 55% 49% 43% 42% 36% 36% 33% 30% 29% 29% 25% 21% 7% 7% 3% e n es ns l g g y ro ic io u u l on lin tio nt dr dr ev at co ca fic I td ric ic ic PV hm hm i ifi te od pi o od sh ra – em yt yt m n m rh rrh to le tio te – ng e ar gy ra a la n yl ti- ti- si io t ab st te bs an an at fe by ra e- su l Li ab st e d R I ng Ad PV – e- e ng n ha R io – ha C at n io bl C at a e- l ab R e- R Paroxysmal Persistent Figure 4 Preferred therapy after a first failed AF ablation both in paroxysmal and persistent AF. *P < 0.05. 680 A.C. Schwab et al. Table 1 Termination of anticoagulation after AF ablation depending on paroxysmal or persistent AF, and the CHA2DS2-VASc score CHA2DS2-VASc, male After 2 Local protocol Based on Based on wearables/ Do not (female) months (%) (%) CIED (%) smartphones (%) stop (%) .............................................................................................................................................. Paroxysmal 0 (1) 72 14 7 2 4 Persistent 0 (1) 57 17 8 6 12 Paroxysmal 1 (2) 34 24 11 6 25 Persistent 1 (2) 22 23 16 8 31 Paroxysmal >2 (3) 10 12 7 2 67 Persistent >2 (3) 8 11 6 1 73 • Self-screening for AF is widely recommended by physicians. the respondents mostly opted for re-ablation with PVI only, while per­ sistent AF recurrence was mostly treated with substrate modification. • A combined endpoint (absence of symptoms and recorded AF) is the This approach seems compatible with the rationale that non- preferred definition for success after ablation. pulmonary triggers may play a significant role in non-paroxysmal • AF type (paroxysmal or persistent) affects the management plan after AF.18 More conservative strategies after failed ablation, such as changing or adding antiarrhythmic drugs, were proposed for both paroxysmal a failed ablation procedure. and persistent AF recurrences. Only 30% of the respondents recom­ • Cessation of anticoagulation after ablation is an option mostly for mended lifestyle modifications after recurrences, despite that it had paroxysmal AF with a low CHA2DS2-VASc score. been proven that risk-factor management results in a reduction in symptom burden and severity of AF, as well as cardiac remodelling.23 Rhythm monitoring According to our survey, 82% of the respondents perform routine rhythm monitoring after AF ablation. There is evidence to show that silent AF Anticoagulation and left atrial appendage might be as clinically relevant as non-silent AF.13 It is shown that the inci­ closure device dence of asymptomatic AF increases after ablation from 5 to 37% and rou­ An important question is whether OAC should be stopped after AF ab­ tine rhythm monitoring can identify those asymptomatic patients.14 lation. From observational retrospective studies, there is weak evidence From the respondents that monitor patients after ablation, almost to show that successful ablation may reduce the risk of cerebrovascular half opt for long-term monitoring instead of short-term monitoring. embolic events, thus allowing the cessation of OAC.24 This risk reduc­ The LINQ AF study found that long-term burden analysis was an accur­ tion may be especially true for patients with a low CHA2DS2-VASc ate diagnosis pattern for AF recurrences, since long-term burden ana­ score, and access to continuous monitoring.25,26 Accordingly, our re­ lysis does not over-reports failures.15 The CASTLE AF study found that spondents showed a tendency to terminate OAC in patients with par­ AF burden at 6 months was predictive of hard clinical outcomes in pa­ oxysmal AF and a low CHA2DS2-VASc score. tients with AF and heart failure.16 Left atrial appendage closure is an alternative therapy for patients for Despite the proved efficacy of long-term monitoring in the detection whom OAC is not suitable. There is evidence showing that the combin­ of asymptomatic AF episodes,17 costs still play a crucial role for its im­ ation of LAAC and an AF ablation procedure is feasible and safe,27,28 plementation into clinical practice. and can improve left atrial function.29 Thus, 74% of our respondents The majority of our respondents recommend the budget-friendly al­ are in favour of performing AF ablation in patients with LAAC. ternative of self-screening, which has shown a sensitivity of 95% and a specificity of 86% and is being increasingly more adopted.18 The Apple Watch study showed promising results with AF self-screening in more than 400 000 patients.19 Conclusion The majority of physicians perform routine monitoring after AF abla­ tion. For most physicians, a combination of clinical and electrocardio­ Success definition graphic endpoints defines a successful result after AF ablation. Our Despite recent attempts to define and clarify the endpoints of AF abla­ results highlight the gap between consensus recommendations and tion,8 the definition of success remains a matter of debate.20 The ma­ real-world clinical practice. jority of our respondents (83%) opted for a composite endpoint based on the absence of symptoms and recorded AF, as the success definition criterion. This echoes a tendency in the literature to consider Supplementary material the combined endpoint21 where both symptoms and actual rhythm play a role. The classic definition of AF diagnosis, according to the Supplementary material is available at Europace online. ESC guidelines, is at least 30 s of recorded AF,3 but there is no consen­ sus on the definition of AF recurrence after ablation. Therefore, the Acknowledgements perceived treatment success may vary from 28.2 to 72%, depending The production of this document is under the responsibility of the Scientific on the required duration and the method used to detect an AF recur­ Initiatives Committee of the European Heart Rhythm Association: Serge rence.10,22 Our study confirms the heterogeneous definition of recur­ Boveda (Chair), Giulio Conte (Co-Chair), Ante Anic, Sergio Barra, Julian rence, that is currently used by the medical community. K.R. Chun, Carlo de Asmundis, Nikolaos Dagres, Michal M. Farkowski, Following an AF recurrence, the management step differs between Jose Guerra, Konstantinos E. Iliodromitis, Kristine Jubele, Jedrzej Kosiuk, cases of paroxysmal or persistent AF. In failed paroxysmal AF ablation, Eloi Marijon, Rui Providencia, and Frits Prinzen. The authors acknowledge Atrial fibrillation ablation: an EHRA survey 681 the EHRA Scientific Research Network centres participating in this survey. 11. Kimura T, Aizawa Y, Kurata N, Nakajima K, Kashimura S, Kunitomi A et al. Assessment A list of these centres can be found on the EHRA website. of atrial fibrillation ablation outcomes with clinic ECG, monthly 24-h Holter ECG, and twice-daily telemonitoring ECG. Heart Vessels 2017;32:317–25. Conflict of interest: A.A. received consulting fees and speaking honor­ 12. Mujović N, Marinković M, Lenarczyk R, Tilz R, Potpara TS. Catheter ablation of atrial aria from Boston Scientific Inc., Farapulse Inc., Galaxy MedicalInc., and fibrillation: an overview for clinicians. Adv Ther 2017;34:1897–917. Biosense & Webster Contracted research from Boston Scientific Inc., 13. Boriani G, Pettorelli D. Atrial fibrillation burden and atrial fibrillation type: clinical signifi­ Farapulse Inc., Galaxy Medical Inc., Biosense & Webster. M.M.F. received cance and impact on the risk of stroke and decision making for long-term anticoagula­ proctoring/speaker fees from BMS/Pfizer, Boehringer Ingelheim, tion. 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