DR‐FLASH Score Is Useful for Identifying Patients With Persistent Atrial Fibrillation Who Require Extensive Catheter Ablation Procedures

Abstract

Background Modification of arrhythmogenic substrates with extensive ablation comprising linear and/or complex fractional atrial electrogram ablation in addition to pulmonary vein isolation (PVI‐plus) can theoretically reduce the recurrence of atrial fibrillation. The DR‐FLASH score (score based on diabetes mellitus, renal dysfunction, persistent form of atrial fibrillation, left atrialdiameter >45 mm, age >65 years, female sex, and hypertension) is reportedly useful for identifying patients with arrhythmogenic substrates. We hypothesized that, in patients with persistent atrial fibrillation, the DR‐FLASH score can be used to classify patients into those who require PVI‐plus and those for whom a PVI‐only strategy is sufficient. Methods and Results This study is a post hoc subanalysis of the a multicenter, randomized controlled, noninferiority trial investigating efficacy and safety of pulmonary vein isolation alone for recurrence prevention compared with extensive ablation in patients with persistent atrial fibrillation (EARNEST‐PVI trial). This analysis focuses on the relationship between DR‐FLASH score and the efficacy of different ablation strategies. We divided the population into 2 groups based on a DR‐FLASH score of 3 points. A total of 469 patients were analyzed. Among those with a DR‐FLASH score >3 (N=279), the event rate of atrial arrhythmia recurrence was significantly lower in the PVI‐plus arm than in the PVI‐only arm (hazard ratio [HR], 0.45 [95% CI, 0.28–0.72]; P <0.001). In contrast, among patients with a DR‐FLASH score ≤3 (N=217), no differences were observed in the event rate of atrial arrhythmia recurrence between the PVI‐only arm and the PVI‐plus arm (HR, 1.08 [95% CI, 0.61–1.89]; P =0.795). There was significant interaction between patients with a DR‐FLASH score >3 and DR‐FLASH score ≤3 ( P value for interaction=0.020). Conclusions The DR‐FLASH score is a useful tool for deciding the catheter ablation strategy for patients with persistent atrial fibrillation. Registration URL: https://clinicaltrials.gov ; Unique identifier: NCT03514693.

Appropriate Selection of Substrate Ablation for Persistent Atrial Fibrillation Using Intraprocedural Assessment

“…15 In a previous subanalysis of the EARNEST-PVI trial, we reported that a DR-FLASH score >3, based on identifiable preprocedural patient characteristics, indicated the effectiveness of the PVI-plus strategy. 7 The present study stratified patients based on electrophysiological findings during ablation procedures, suggesting that combining both approaches could enhance stratification efficacy. Although the analysis was exploratory in nature, we divided patients into groups according to DR-FLASH score (>3 or ≤3) and whether they were part of Group D. The results indicated that patients with DR-FLASH scores >3, particularly those in Group D, may especially benefit from the PVI-plus strategy.…”

“…6 Using the 1-year followup results, we reported that a DR-FLASH score (based on diabetes, renal dysfunction, PerAF, left atrial [LA] diameter >45 mm, age >65 years, female sex, and hypertension) >3, which is a predictor of a low voltage area, could distinguish patients who would and would not benefit from additional substrate ablation. 7 Considering the results of previous studies that could not prove the efficacy of additional substrate ablation, 1,8 there is likely to be a certain proportion of the population who will not benefit from additional substrate ablation. Theoretically, additional ablation has an increased risk of complications and it is worth detecting specific patients who would benefit from the PVI-plus strategy.…”

Long‐Term Impact of Additional Ablation After Pulmonary Vein Isolation: Results From EARNEST‐PVI Trial

“…A subanalysis of the EARNEST‐PVI trial reported that the efficacy of left atrial ablation in addition to PVI was enhanced in patients with a high DR‐FLASH score, a risk score that predicts the presence of left atrial low‐voltage areas. 25 , 26 A prior study suggested that complete conduction block could be easily achieved in areas with reduced bipolar voltage. 27 In addition, left atrial linear ablation guided by low‐voltage areas demonstrated better rhythm outcomes than linear ablation without voltage guidance.…”

Left Atrial Volume Assessment in Atrial Fibrillation Patients undergoing Ablation, using 2-D Echocardiography and Invasive Three-Dimensional CARTO and its Predictive Value in Recurrence of Atrial Fibrillation after Ablation

“…According to reports, it can be used to detect patients who have arrhythmogenic substrates. Based on the DR-FLASH score, patients with persistent atrial fibrillation can be categorized into two groups, according to Sato et al (23) hypothesis: those who require PVI-plus and those who can get by with PVI alone.…”