Predictive modeling and external validation of late atrial fibrillation recurrence following catheter ablation

Abstract

Aim: To identify factors associated with late atrial fibrillation (AF) recurrence after radiofrequency catheter ablation and to develop a nomogram for individualized risk prediction, followed by external validation in an independent cohort.

Methods: We conducted a retrospective cohort study of patients with AF who underwent catheter ablation at Tongji Hospital (training cohort, January 2020-December 2022) and the Second Hospital of Lanzhou University (validation cohort, June 2020-June 2023). Follow-up visits were scheduled at 1, 3, 6, 12, and 18 months after the procedure. Candidate predictors were identified using the Boruta algorithm and the least absolute shrinkage and selection operator. Selected variables were then entered into multivariable Cox proportional hazards models. Model performance was evaluated using Harrell’s C-index, time-dependent area under the receiver operating characteristic curve, calibration plots, and decision curve analysis.

Results: A total of 256 patients in the training cohort and 203 in the validation cohort were included, with a median follow-up of 12 months. Late AF recurrence occurred in 21.9% and 21.2% of patients, respectively. Six variables were included in the final model: early recurrence (HR = 7.616), left atrial diameter (HR = 1.684), intraoperative electrical cardioversion (HR = 1.423), serum creatinine (HR = 1.018), use of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI) (HR = 0.426), and AF duration (HR = 1.003). The nomogram showed good discrimination, calibration, and clinical usefulness in both cohorts.

Conclusion: We developed and externally validated a six-variable nomogram for predicting late AF recurrence after catheter ablation. This model may support individualized risk stratification and guide post-ablation management.

Keywords

Electrical cardioversion / nomogram / recurrence / risk prediction / atrial fibrillation

References

[1] Lippi G,Cervellin G.Global epidemiology of atrial fibrillation: an increasing epidemic and public health challenge.Int J Stroke2020;16:217-21

[2] Joglar JA,Armbruster AL.2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Circulation2024;149:e1-156

[3] Al-khatib SM,Buxton AE.Research needs and priorities for catheter ablation of atrial fibrillation: a report from a national heart, lung, and blood institute virtual workshop.Circulation2020;141:482-92 PMCID:PMC7043236

[4] Reddy VY,Natale A.Pulsed field or conventional thermal ablation for paroxysmal atrial fibrillation.N Engl J Med2023;389:1660-71

[5] Schnabel RB,Arbelo E.Early diagnosis and better rhythm management to improve outcomes in patients with atrial fibrillation: the 8th AFNET/EHRA consensus conference.EP Europace2023;25:6-27

[6] Benali K,Haïssaguerre M.Impact of catheter ablation of atrial fibrillation on disease progression.JACC Clin Electrophysiol2025;11:421-35

[7] Modin D,Gislason G.Catheter ablation for atrial fibrillation is associated with lower incidence of heart failure and death.EP Europace2020;22:74-83

[8] Cappato R,Chen S.Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation.Circ Arrhythm Electrophysiol2010;3:32-8

[9] Luik A,Hörmann P.Cryoballoon vs. open irrigated radiofrequency ablation for paroxysmal atrial fibrillation: long-term FreezeAF outcomes.BMC Cardiovasc Disord2017;17:135 PMCID:PMC5445510

[10] Kornej J,Shoemaker MB.The APPLE score: a novel and simple score for the prediction of rhythm outcomes after catheter ablation of atrial fibrillation.Clin Res Cardiol2015;104:871-6 PMCID:PMC4726453

[11] Winkle RA,Mead RH.Predicting atrial fibrillation ablation outcome: the CAAP-AF score.Heart Rhythm2016;13:2119-25

[12] Mujović N,Marković N,Lip GYH.Prediction of very late arrhythmia recurrence after radiofrequency catheter ablation of atrial fibrillation: the MB-LATER clinical score.Sci Rep2017;7:40828 PMCID:PMC5247745

[13] Mesquita J,Cavaco D.Development and validation of a risk score for predicting atrial fibrillation recurrence after a first catheter ablation procedure - ATLAS score.EP Europace2018;20:f428-35

[14] Marrouche NF,Hindricks G.Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study.JAMA2014;311:498

[15] Collins GS,Altman DG.Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement.BMJ2015;350:g7594

[16] Zhang H,Yang Z.Development and validation of prognostic models for bleeding and ischemia in elderly patients with comorbid acute coronary syndrome and atrial fibrillation.J Am Heart Assoc2024;13:e035086 PMCID:PMC11935593

[17] Hindricks G,Dagres N.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 J2021;42:373-498

[18] Bergonti M,Marcon L.Left ventricular functional recovery after atrial fibrillation catheter ablation in heart failure: a prediction model.Eur Heart J2023;44:3327-35

[19] Guan C,Zhao Y.Interpretable machine learning model for new-onset atrial fibrillation prediction in critically ill patients: a multi-center study.Crit Care2024;28:349 PMCID:PMC11523862

[20] Balachandran VP,Smith JJ.Nomograms in oncology: more than meets the eye.Lancet Oncol2015;16:e173-80 PMCID:PMC4465353

[21] Fitzgerald M,Lewis RJ.Decision curve analysis.JAMA2015;313:409

[22] Yang J,Liu Q.Brief introduction of medical database and data mining technology in big data era.J Evid Based Med2020;13:57-69 PMCID:PMC7065247

[23] Stekhoven DJ.MissForest—non-parametric missing value imputation for mixed-type data.Bioinformatics2012;28:112-8

[24] Hu J,Tong X.When to consider logistic LASSO regression in multivariate analysis?.Eur J Surg Oncol2021;47:2206

[25] Wang J,Duan S.Multimodal data-driven prognostic model for predicting long‐term prognosis in patients with ischemic cardiomyopathy and heart failure with preserved ejection fraction after coronary artery bypass grafting: a multicenter cohort study.J Am Heart Assoc2024;13:e036970 PMCID:PMC11681600

[26] Winkle RA,Engel G.Long-term results of atrial fibrillation ablation: the importance of all initial ablation failures undergoing a repeat ablation.Am Heart J2011;162:193-200

[27] Soffer S,Barash Y,Zimlichman E.Predicting in-hospital mortality at admission to the medical ward: a big-data machine learning model.Am J Med2021;134:227-34.e4

[28] Ma G,Zhang Z,Zhang J.A novel nomogram for predicting the recurrence of atrial fibrillation in patients treated with first-time radiofrequency catheter ablation for atrial fibrillation.Front Cardiovasc Med2024;11:1397287 PMCID:PMC11371565

[29] Calkins H,Cappato R.2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation.EP Europace2018;20:e1-160

[30] Stabile G,Verlato R.Predictive role of early recurrence of atrial fibrillation after cryoballoon ablation.EP Europace2020;22:1798-804

[31] Njoku A,Arora R.Left atrial volume predicts atrial fibrillation recurrence after radiofrequency ablation: a meta-analysis.EP Europace2018;20:33-42

[32] Choi SH,Kim D.Late recurrence of atrial fibrillation 5 years after catheter ablation: predictors and outcome.EP Europace2023;25:euad113 PMCID:PMC10228616

[33] Henn MC,Miller JR.Late outcomes after the Cox maze IV procedure for atrial fibrillation.J Thorac Cardiovasc Surg2015;150:1168-78.e2 PMCID:PMC4637220

[34] Luong C,Bennett M.Right atrial volume is superior to left atrial volume for prediction of atrial fibrillation recurrence after direct current cardioversion.Can J Cardiol2015;31:29-35

[35] Takagi T,Asami M.Impact of right atrial structural remodeling on recurrence after ablation for atrial fibrillation.J Arrhythm2021;37:597-606 PMCID:PMC8207433

[36] Bisbal F,Ferrero‐de‐Loma‐Osorio A.Diagnosis‐to‐ablation time in atrial fibrillation: a modifiable factor relevant to clinical outcome.J Cardiovasc Electrophysiol2019;30:1483-90

[37] Lin M,Zhang K.Optimal timing for atrial fibrillation patients to undergo catheter ablation.Commun Med2025;5:245 PMCID:PMC12182564