Variation and clinical consequences of wait-times for atrial fibrillation ablation: population level study in Ontario, Canada

Abstract

Aims Atrial fibrillation (AF) is the most common cardiac rhythm disorder. Emerging evidence supporting the efficacy of catheter ablation in managing AF has led to increased demand for this therapy, potentially outpacing the capacity to perform this procedure. Mismatch between demand and capacity for AF ablation results in wait-times which have not been comprehensively evaluated at a population level. Additionally, the consequences of such delays in AF ablation, namely the risk of hospitalization or adverse events, have not been studied. Methods and results This observational cohort study included adults referred for catheter ablation to treat AF in Ontario, Canada, between 1 April 2016 and 31 March 2020. Wait-time was defined from referral to the earliest of ablation, death, off-list, or the study endpoint of 31 March 2022. The outcomes of interest included a composite of death, hospitalization for AF/heart failure, and emergency department visit for AF/heart failure. Our study cohort included 6253 patients referred for de novo AF ablation. The median wait-time for patients who received and who did not receive ablation was 218 days (IQR: 112–363) and 520 days (IQR: 270–763), respectively. Wait-time increased consistently for patients referred between October 2017 and March 2020. Mortality was rare, but significant morbidity was observed, affecting 19.2% of patients on the waitlist for AF ablation. Paroxysmal AF was associated with a statistically significant greater risk for adverse outcomes on the waitlist (HR 1.51, 95% CI 1.18–1.93). Conclusion Wait-times for AF ablation are increasing and are associated with significant morbidity.

EUropean real-world outcomes with Pulsed field ablatiOn in patients with symptomatic atRIAl fibrillation: lessons from the multi-centre EU-PORIA registry

“… 3–5 , 34 Future growing demand may even prolong the already existing, extensive waiting times for an AF ablation in some geographies. 35 Nonetheless, during decision-making with a symptomatic AF patient, the merits and demerits of all treatment options should be carefully considered for an optimal individual counselling. Further studies are needed to answer questions with regards to ablation timing, lesion sets, and workflow to ensure patient safety.…”

Managing arrhythmia in cardiac resynchronisation therapy

“…There is also discrepancy between whether to utilise pre-enrolment or pre-intervention AF duration, a vital distinction to make when international waiting times for AF ablations continue to climb. Qeska et al's observational study of 6,253 patients (including 18.8% with unspecified HF) referred for first AF ablation suggests long wait-times are associated with substantial morbidity risk; however, by not adjusting for initial AF diagnosis-to-referral time [which averaged 741 ± 581 days (mean ± SD) across the cohort], it is difficult to accurately determine the proportional impact long wait-times had compared to any initial delay in referral ( 54 ). In contrast, Kalman et al's recently published RCT suggests delaying first AF ablation from 1 month to 12 months after enrolment makes no difference to ablation success rates at 1 year in patients with either paroxysmal or persistent AF (HR: 1.12; 95% CI: 0.59–2.13, p = 0.7).…”

Very-high-power Short-duration Ablation versus Conventional Ablation for Pulmonary Vein Isolation in Atrial Fibrillation: Systematic Review and Meta-analysis

“…Meanwhile, waiting time and longer time to ablation from diagnosis were associated with increased morbidity and AF recurrence. [ 3 , 4 ]…”

“…Meanwhile, waiting time and longer time to ablation from diagnosis were associated with increased morbidity and AF recurrence. 3,4 One of the current approaches is very-high-power short-duration (VHPSD) ablation, which can significantly shorten the procedure time. [5][6][7] By increasing the power output it is possible to reduce the duration of ablation per lesion tag to 4-7 seconds, along with the potential creation of shallower but wider lesions, thus facilitating complete isolation while also reducing the procedure time.…”