Waiting time for pulmonary vein isolation: evaluation of atrial fibrillation progression and complications

Background/Introduction
Due to high demand of pulmonary vein isolation (PVI) there is prolonged waiting time. Delays in treatment may lead to atrial fibrillation (AF) progression and the development of complications.

Purpose
Our study aimed to evaluate the impact of waiting time on AF progression and complication rates in patients included in the PVI waiting queue. By understanding how delays in PVI affect AF outcomes, we hope to provide insights that can guide clinical prioritization and improve patient management strategies.

Methods
Data was used from our Clinical University Hospital pulmonary vein isolation (PVI) registry. Standardized questionnaire was designed to capture active PVI waiting list patient’s progression of AF, cause of acute admission and associated complications due to AF.

Results
A total of 934 patients have been awaiting PVI from 2016 up to this moment. 9% (n = 84) of patients with a mean age of 65.8 ± 10.1 years and a mean CHA2DS2-VASc score of 3.14 ± 2.0 of which 53.6% (n = 45) were females, have undergone follow-up. The median waiting time for follow-up was 65.2 months (interquartile range: 59.0–72.4 months). AF form has changed significantly while on the PVI waitlist. Paroxysmal and persistent AF has decreased from 59.5% to 57.1% (p < 0.01) and 40.5% to 27.4% (p < 0.01), respectively. AF progressed to a permanent form in 15.5% (n =13) of patients. Additionally, the Wilcoxon Signed-Rank Test indicated a statistically significant worsening of the European Heart Rhythm Association (EHRA) score over time (p < 0.05). Negative binomial regression analysis revealed that AF progression significantly increased the hospitalization rate (p < 0.01), though it did not correlate with waiting time (p = 0.73). In total, followed-up patients experienced 210 hospitalizations due to AF paroxysms and 91 electrical cardioversions were performed. 2.4% (n = 2) and 1.2% (n = 1) of patients experienced ischemic and hemorrhagic strokes, respectively. 7.1% (n = 6) of patients had other causes of hospitalization, such as chronic heart failure decompensation, syncope or bleeding complications. At follow-up, the mean left atrial volume index (LAVI) was 37.9 ± 8.6 ml/m², and the mean left ventricular ejection fraction (LVEF) was 59.9 ± 5.9%. Spearman’s correlation analysis showed no significant association between waiting time and changes in LAVI (rho = 0.091, p = 0.42) or LVEF (rho = -0.007, p = 0.95). 35.7% (n = 30) of patients were excluded from the PVI waiting list, primarily due to frequency control strategy or asymptomatic AF.

Conclusion(s)
Our findings suggest that prolonged waiting times for PVI can lead to AF progression and increased hospitalizations, emphasizing the need for timely intervention in symptomatic patients. Additionally, regular re-evaluation of patients on the waitlist may help in optimizing resource use by prioritizing those who are most likely to benefit from PVI.