Figure 4 Forest plot regarding ORs based on DC post-ablation
for predicting AF recurrence. Abbreviations: OR, odds ratio; SE,
standard error; CI, confidence interval; REM, random-effect model; DC,
deceleration capacity; AF, atrial fibrillation.
Discussion
To our best knowledge, the present study was the first systematic review
and meta-analysis evaluating the relationship between the DC index and
AF recurrence post-ablation. This study demonstrated that
ablation-treated patients with AF
recurrence had the higher DC post-ablation compared to those with
freedom of AF recurrence, which was present up to 3 months
post-ablation. Furthermore, we found that the high
DC post-ablation was associated with
the risk of AF recurrence in patients treated with CA.
Comparing DC between pre- and post-ablation (Figure 3), we observed that
the denervation effect, especially attenuation of cardiac
parasympathetic activity, was involved in the electrophysiological
mechanisms of CA, which was consistent with the previous research using
the HRV parameters to assess autonomic function.28,29A recent meta-analysis regarding the HRV parameters have reported that
higher root mean square of successive RR-interval differences (rMSSD)
and absolute power of the high-frequency (HF) band, the indicators of
parasympathetic activity, were associated with the increasing risk of
arrhythmia recurrence in ablation-treated patients, becoming independent
predictors for AF recurrence.30 These findings, as
well as our results that the higher DC post-ablation was a risk factor
for AF recurrence, indicated that enhanced vagal activity was of
substantial importance in the development of recurrent AF.
We also noticed that both patients with early recurrence and late
recurrence had the higher DC post-ablation in relation to those without
recurrence. In terms of late recurrence, electrical reconnections of PVs
isolated with CA previously were regarded as the predominant culprit,
where majority of recurrent AF triggers probably
originated.31,32 A recent study has showed that
intensified vagal tone estimated with DC, as well as absolute power of
the very-low-frequency (VLF) band and mean of the SDs of all the NN
intervals for each 5 min segment (SDNNI), was observed in
ablation-treated patients with reconnected PVs compared to those without
reconnections.12 It was suggested that cardiac
reinnervation, especially parasympathetic reinnervation, might be an
indispensable process in reconnections of PVs, presumably accounting for
the higher DC post-ablation in AF patients with late recurrence. In the
subgroup analysis, it was interesting that patients with early
recurrence appeared to have the higher DC within the first 3 days in
relation to those with late recurrence. It was reported that the
underlying mechanisms of early recurrence were different from those of
late recurrence. Early recurrence, especially during the first month
post-ablation, was probably associated with inflammatory reactions and
temporary autonomic imbalances resulting in a transient PV development
arrhythmogenicity, while early recurrence during the late phase of a
blanking period was likely to be related to PV reconnections, similar to
the main cause of late recurrence.7,33,34 Apart from
PV reconnections, temporary imbalances between vagal and sympathetic
activity were likely to contribute to the relatively higher DC
post-ablation in patients with early recurrence. Higher vagal tone
assessed with DC post-ablation was observed in ablation-treated patients
with early recurrence, which might provide a novel approach to interpret
why AF patients treated with CA who suffered from early recurrence had a
higher rate of long-term recurrence.
However, there were several limitations in this study. Firstly, since
most of the included studies enrolled patients with paroxysmal AF, the
relationship between DC and persistent AF prognosis affected by numerous
factors was still challenging to research. Secondly, given only one
study involving DC in the relatively small number of patients with early
recurrence, the association between DC and early recurrence comprised of
early and late stage of a blanking period needs to be further
investigated. Finally, publication bias was illustrated with funnel
plots, which could not be evaluated accurately due to less than 10
studies included. Multicenter, prospective cohort studies with the large
number of participants enrolled are needed to provide high-quality
evidence in the future.
Conclusion
Patients with AF recurrence had the higher DC post-ablation compared to
those without recurrence. The higher DC post-ablation was related to the
risk of AF recurrence, suggesting that DC may act as a prognostic
indicator in AF patients treated with CA.
Acknowledgements
This study was supported by Zhong Nanshan Medical Foundation of
Guangdong Province (Grant Number: T2022-ZX041) and hospital clinical
scientific research funds from Chinese Academy of Medical Sciences,
Fuwai hospital (Grant Number: 2022-GSP-QZ-4).
References
1. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart Disease and Stroke
Statistics-2023 Update: A Report From the American Heart Association.Circulation. 2023;147(8):e93-e621.
2. Senoo K, Yukawa A, Ohkura T, et al. Depression and quality of life in
older adults with atrial fibrillation: A cross-sectional community-based
study. Geriatr Gerontol Int. 2022;22(7):505-510.
3. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the
diagnosis and management of atrial fibrillation developed in
collaboration with the European Association for Cardio-Thoracic Surgery
(EACTS): The Task Force for the diagnosis and management of atrial
fibrillation of the European Society of Cardiology (ESC) Developed with
the special contribution of the European Heart Rhythm Association (EHRA)
of the ESC. Eur Heart J. 2021;42(5):373-498.
4. Buist TJ, Zipes DP, Elvan A. Atrial fibrillation ablation strategies
and technologies: past, present, and future. Clin Res Cardiol.2021;110(6):775-788.
5. Narayan SM, Krummen DE, Clopton P, et al. Direct or coincidental
elimination of stable rotors or focal sources may explain successful
atrial fibrillation ablation: on-treatment analysis of the CONFIRM trial
(Conventional ablation for AF with or without focal impulse and rotor
modulation). J Am Coll Cardiol. 2013;62(2):138-147.
6. Chen PS, Chen LS, Fishbein MC, et al. Role of the autonomic nervous
system in atrial fibrillation: pathophysiology and therapy. Circ
Res. 2014;114(9):1500-1515.
7. Onishi N, Kaitani K, Nakagawa Y, et al. The association between
late-phase early recurrence within the blanking period after atrial
fibrillation catheter ablation and long-term recurrence: Insights from a
large-scale multicenter study. Int J Cardiol. 2021;341:39-45.
8. Ganesan AN, Shipp NJ, Brooks AG, et al. Long-term outcomes of
catheter ablation of atrial fibrillation: a systematic review and
meta-analysis. J Am Heart Assoc. 2013;2(2):e004549.
9. Calkins H, Hindricks G, Cappato R, et al. 2017
HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and
surgical ablation of atrial fibrillation. Europace.2018;20(1):e1-e160.
10. Hodges G, Bang CN, Torp-Pedersen C, et al. Significance of early
recurrence of atrial fibrillation after catheter ablation: a nationwide
Danish cohort study. J Interv Card Electrophysiol.2021;60(2):271-278.
11. Erhard N, Metzner A, Fink T. Late arrhythmia recurrence after atrial
fibrillation ablation: incidence, mechanisms and clinical implications.Herzschrittmacherther Elektrophysiol. 2022;33(1):71-76.
12. Calburean PA, Osorio TG, Sorgente A, et al. High vagal tone predicts
pulmonary vein reconnection after cryoballoon ablation for paroxysmal
atrial fibrillation. Pacing Clin Electrophysiol.2021;44(12):2075-2083.
13. Pan Q, Zhou G, Wang R, et al. Do the deceleration/acceleration
capacities of heart rate reflect cardiac sympathetic or vagal activity?
A model study. Med Biol Eng Comput. 2016;54(12):1921-1933.
14. Bauer A, Deisenhofer I, Schneider R, et al. Effects of
circumferential or segmental pulmonary vein ablation for paroxysmal
atrial fibrillation on cardiac autonomic function. Heart Rhythm.2006;3(12):1428-1435.
15. Bauer A, Kantelhardt JW, Barthel P, et al. Deceleration capacity of
heart rate as a predictor of mortality after myocardial infarction:
cohort study. Lancet. 2006;367(9523):1674-1681.
16. Calburean PA, Osorio TG, Sieira J, et al. High parasympathetic
activity as reflected by deceleration capacity predicts atrial
fibrillation recurrence after repeated catheter ablation procedure.J Interv Card Electrophysiol. 2021;60(1):21-29.
17. Chen Z, Yang Y, Zou C, et al. Low heart deceleration capacity imply
higher atrial fibrillation-free rate after ablation. Sci Rep.2018;8(1):5537.
18. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of
observational studies in epidemiology: a proposal for reporting.
Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.JAMA. 2000;283(15):2008-2012.
19. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement:
an updated guideline for reporting systematic reviews. BMJ.2021;372:n71.
20. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the
assessment of the quality of nonrandomized studies in meta-analyses.Eur J Epidemiol. 2010;25(9):603-605.
21. Sterne JA, Sutton AJ, Ioannidis JP, et al. Recommendations for
examining and interpreting funnel plot asymmetry in meta-analyses of
randomised controlled trials. BMJ. 2011;343:d4002.
22. Chen Z, Zou C, Li X, et al. Predictive value of deceleration
capacity of heart rate in recurrence after circumferential pulmonary
vein isolation in atrial fibrillation. Journal of Clinical
Cardiology. 2019;35(6):544-548.
23. Kanda S, Amino M, Sakama S, et al. Relation Between Autonomic
Nervous Activity after Pulmonary Vein Isolation and Recurrence in
Paroxysmal Atrial Fibrillation Patients. Tokai J Exp Clin Med.2018;43(4):153-160.
24. Li Y. Prognostic value of heart rate variability and deceleration
capacity in patients with atrial fibrillation after radiofrequency
ablation. Prevention and Treatment of Cardiovascular Disease.2022;12(21):33-36.
25. Song W, Yan W, Zhang H, et al. Predictive value of deceleration
capacity of heart rate combined with fibrillatory wave amplitude on lead
V1 of surface electrocardiography in atrial fibrillation patients with
recurrence after radiofrequency catheter ablation. Chin J Inter
Rad (Electronic Edition). 2016;4(04):202-206.
26. Zhang Y, Zhou J. Effect of heart rate deceleration on recurrence in
patients with paroxysmal atrial fibrillation after radiofrequency
ablation and its clinical significance. China Modern Doctor.2019;57(35):11-14.
27. Zhao H, Duan L, Wang P, et al. Changes of heart rate variability and
bradycardia after radiofrequency ablation of paroxysmal atrial
fibrillation and its early recurrence. Journal of North Sichuan
Medical College. 2020;35(2):232-235.
28. Zhu Z, Wang W, Cheng Y, et al. The predictive value of heart rate
variability indices tested in early period after radiofrequency catheter
ablation for the recurrence of atrial fibrillation. J Cardiovasc
Electrophysiol. 2020;31(6):1350-1355.
29. Yamada T, Yoshida N, Murakami Y, et al. The difference in autonomic
denervation and its effect on atrial fibrillation recurrence between the
standard segmental and circumferential pulmonary vein isolation
techniques. Europace. 2009;11(12):1612-1619.
30. Zhang E, Liang S, Sun T, et al. Prognostic value of heart rate
variability in atrial fibrillation recurrence following catheter
ablation: A systematic review and meta-analysis. Front Cardiovasc
Med. 2022;9:1048398.
31. Gerstenfeld EP, Callans DJ, Dixit S, et al. Incidence and location
of focal atrial fibrillation triggers in patients undergoing repeat
pulmonary vein isolation: implications for ablation strategies. J
Cardiovasc Electrophysiol. 2003;14(7):685-690.
32. Daimee UA, Akhtar T, Boyle TA, et al. Repeat catheter ablation for
recurrent atrial fibrillation: Electrophysiologic findings and clinical
outcomes. J Cardiovasc Electrophysiol. 2021;32(3):628-638.
33. Liang JJ, Dixit S, Santangeli P. Mechanisms and clinical
significance of early recurrences of atrial arrhythmias after catheter
ablation for atrial fibrillation. World J Cardiol.2016;8(11):638-646.
34. Liang JJ, Elafros MA, Chik WW, et al. Early recurrence of atrial
arrhythmias following pulmonary vein antral isolation: Timing and
frequency of early recurrences predicts long-term ablation success.Heart Rhythm. 2015;12(12):2461-2468.