Log in to MyACC
Outcomes of Pulmonary Vein Isolation in Athletes
Quick Takes
- Athletes are at higher risk for developing AF. Potential factors include intensity and/or type of exercise, vagotonia, stimulant usage, LA structural changes, inflammation, and fibrosis.
- Medical management, especially in younger patients, is often not well tolerated.
- This study supports early consideration of catheter ablation in symptomatic athletes with AF.
Study Questions:
What are the efficacy and physiological effects of catheter ablation for atrial fibrillation (AF) performed in athletes with AF?
Methods:
Athletes were identified from a single-center database of consecutive patients undergoing catheter ablation for AF over a 15-year period. An “athlete” was defined as someone: 1) competing in a structured training program, or 2) exercising frequently and vigorously (>6.0 METs). Two of the exclusion criteria were age >65 years old and body mass index (BMI) >30 mg/m2. Ablation was performed with the cryoballoon in two patients and radiofrequency ablation in the rest. Only first-time ablation patients were included, but the ablation approach was not limited to isolation of the pulmonary veins—additional lines were “typically” performed. Exercise treadmill tests (ETTs) had to be performed within 5 years of the ablation. Diagnosis to ablation time was defined as time from initial AF diagnosis to ablation. Arrhythmia recurrence was defined as >30 seconds of atrial arrhythmia recorded after the usual 3-month post-ablation blanking period and procedure success was defined as freedom from antiarrhythmics. All patients underwent evaluation for pulmonary stenosis 3-6 months post-procedure. Resting heart rate was assessed by electrocardiograms (ECGs) in sinus rhythm pre- and post-procedure. The athlete cohort was compared to a matched group of nonathletes from the original database.
Results:
The study cohort was comprised of 144 athletes (93% men; mean age, 50 years; 72% endurance sports; 67% paroxysmal, 26% persistent, and 6% long-standing persistent AF). Single-procedure success was 75%, 68%, and 33% at 1 year for paroxysmal, persistent, and long-standing persistent AF, respectively. Accounting for multiple procedures, success improved to 86%, 76%, and 56% in respective groups by the end of follow-up. Rate of arrhythmia recurrence was the same in the matched cohort of nonathletes; left atrial (LA) diameters and volumes were also similar. Arrhythmia-free survival was similar between competitive and noncompetitive, endurance versus nonendurance athletes. Longer diagnosis-to-ablation time was associated with arrhythmia recurrence, and pulmonary vein isolation within 2 years of diagnosis was significantly associated with lower recurrence. Resting heart rate at 1 year was increased by approximately 10 bpm compared to preablation in the 39 patients with data available. In the eight patients with pre- and post-procedure ETTs, exercise capacity was essentially unchanged, although heart rate recovery at 1 minute was significantly reduced.
Conclusions:
AF ablation, especially when referred early, is an effective therapy in athletes with paroxysmal and persistent AF, with similar recurrence rates compared to nonathletes. Sustained cardioautonomic changes were observed post-procedure.
Perspective:
This is the largest and most detailed study to date of an athletic population undergoing catheter ablation for AF. It supports consideration of early ablation in symptomatic athletes, especially at the paroxysmal stage. The elevated heart rate post-ablation usually resolves in most patients, but seems to be a persistent manifestation of autonomic modulation post-ablation in athletes. This potential side effect of ablation can be symptomatic and should be discussed with patients preprocedure.
The retrospective design highlights some limitations and future areas of study. Defining who was an “athlete” depended on documentation and adjudication. Assessment of change in symptoms, such as via a symptom score, was not provided. Furthermore, few patients had both pre- and post-ETT, limiting assessment of the effects of ablation and rhythm control on baseline exercise (which might not have been running). Heart rates were assessed by ECG in the clinic rather than continuous monitoring. Different rhythm control strategies, such as lifestyle modification (e.g., weight loss), pill in the pocket or daily antiarrhythmic therapy, and catheter ablation were not directly compared. Last, this study was not able to assess the impact of ablation on LA and pulmonary vein function. Ablation strategies have shifted in recent years to focusing on pulmonary vein isolation only, and this might be particularly important in the endurance athlete.
Future investigation should build on this study by incorporating prospective pre- and post-ablation assessments of LA function and scarring via echocardiography (including strain) and cardiac magnetic resonance imaging, and evaluations of athletic performance.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging
Keywords: Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Athletes, Catheter Ablation, Diagnostic Imaging, Electrocardiography, Exercise Test, Exercise Tolerance, Physical Endurance, Pulmonary Valve Stenosis, Pulmonary Veins, Secondary Prevention
< Back to Listings
