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).
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