Why Say Never—Ablation of “Permanent” Atrial Fibrillation?

Objectives: Persistent atrial fibrillation (AF) is often accepted to be “permanent” in low- and a-symptomatic patients, denying interventional therapy. These patients underlie the risk of anticoagulation-associated bleeding, stroke, progressive remodeling, reduced cardiac function, and survival. However, concomitant atrial ablation in cardiac surgery reaches high rates of freedom from AF (FAF). We aimed to show operative success of concomitant ablation in “permanent” AF and risk factors for therapeutic failure.

Methods and Patients: All patients (paroxysmal [n = 21]; “permanent” [n = 43] AF) underwent standardized epicardial bipolar radiofrequency atrial ablation. Surgery and follow-up took place at our department (6 months, electrocardiogram, ER-readout, 24-hour Holter, echocardiography, blood sample). We defined FAF following consensus. We offered electrophysiological therapy in case of AF maintenance (over 24 months) and evaluated risk factors for therapeutic failure.

Results: In this study, 92% paroxysmal and 63% “permanent” AFs reached FAF (month 24). Mortality was as expected (5.3 ± 0.2%, paroxysmal; 4.1 ± 0.3%, persistent; p < 0.05 vs. EuroSCORE II; 6.1 ± 0.7% [paroxysmal]; 6.4 ± 0.4% [permanent]). No strokes occurred. FAF induced atrial re-remodeling and gain of cardiac function (left atrial diameter [−6.7 ± 2.2 mm]/LVEF [+7.3 ± 2.8%]). Failure resulted in further atrial dilation (+8.0 ± 1.0 mm) and LVEF reduction (−7.0 ± 1.3%) (p < 0.05). Increased atrial diameter, age, and obesity correlated to therapeutic failure. Electrophysiological re-examination reached further FAF during follow-up.

Conclusion: Atrial remodeling, age, and obesity influence therapeutic long-term success and impact therapeutic planning. However, FAF is likely, reachable and beneficial even in formerly “permanent” AF. Moreover, absolute denial of ablation would render additive reduction of morbidity impossible. Thus, “never say never” and ablate these patients.