Catheter ablation for atrial fibrillation in patients with tricuspid regurgitation

Contemporary guidelines recommend early rhythm control strategies including catheter ablation (CA) for patients with symptomatic atrial fibrillation. The impact of coexisting tricuspid regurgitation (TR) on procedural characteristics and efficacy of patients undergoing CA for AF remains unclear.

To assess procedural characteristics and efficacy of patients with moderate or severe TR undergoing a CA for AF.

This retrospective analysis included prospectively enrolled patients with moderate or severe TR undergoing CA for AF in the SWISS-AF PVI Registry. All patients received a transesophageal echocardiography before CA. Patient characteristics, procedural characteristics and long-term follow-up data including serial echocardiograms were obtained in all patients.

133 patients were included, 127 patients (95%) with moderate TR and 6 patients (5%) with severe TR (median age 72 [68 - 76] years, 55% female). Paroxysmal AF was present in 57 patients (43%) and persistent AF in 76 patients (57%). LA diameter, LVEF, RV/RA gradient and RA area were 43 [39 - 48] mm, 56 [45 - 63] %, 27 [21 - 35] mmHg and 25 [20 - 32] cm2, respectively. The used ablation modalities were radiofrequency in 51%, pulsed-field ablation in 38% and cryoballoon ablation in 11%. The median procedural duration was 68 [54 - 84] min, the left atrial dwell time 49 [36 - 63] min and the fluoroscopy time was 8 [4 - 13] min. A total of 2 complications (2%) were observed. The median follow-up time was 310 [105 - 526] days, and the 1-year Kaplan-Meier estimate for atrial arrhythmia recurrence-free survival was 60%. 63% of patients showed a TR improvement after CA during follow-up. When comparing TR improvement in patients with or without recurrence, a higher proportion of patients without recurrence showed a TR improvement: 79% vs 51%, p = 0.017 (Figure). Among the 6 patients with severe TR, 2 patients (33%) underwent interventional tricuspid valve reconstruction during follow-up.

Recurrence-free survival rate was 60% after 1 year. Despite the high AF recurrence rates in patients undergoing CA with significant TR, CA resulting in maintenance of sinus rhythm appeared to improve the severity of TR, suggesting a possible induction of reverse positive atrial and tricuspid valvular remodeling.

Figure