Atrial fibrillation (AF) is the most frequent arrhythmia, and its incidence increases with age. Although AF is not an immediately life-threatening arrhythmia, the management of AF in the elderly is challenging, as it is normally associated with comorbidities and frailty. Treating elderly patients with AF remains challenging, as antiarrhythmic drugs (AADs) are not frequently effective, and they pose risks due to common side effects. Anticoagulation has proven to be effective in preventing ischemic stroke in this population; however, it also imposes a risk of bleeding complications.^1-4

As AF progression is associated with a decrease in quality of life and, with time, becomes irreversible or less amenable to treatment, rhythm control is a relevant choice. The rhythm control strategy refers to attempts to restore sinus rhythm and may involve a combination of approaches, including cardioversion, antiarrhythmic medication, and catheter ablation (CA). The primary indication for rhythm control is to reduce the AF burden and its effects, including AF-related symptoms, stroke, heart failure, hospitalizations, and poor quality of life.^5-10

The state-of-the-art management of AF, as recommended by the guidelines, supports the implementation of the AF Better Care (ABC) holistic Pathway (A, anticoagulation/avoid stroke; B, better symptom management; C, cardiovascular and comorbidity optimization), which has been associated with a lower risk of all-cause death. The ABC Pathway streamlines the integrated care of patients with AF across all healthcare levels and among different specialties.^5-9

CA emerged more than 20 years ago, and its technology has advanced significantly. It is considered an important and effective approach to maintain a normal sinus rhythm. When performed by appropriately trained operators, AF CA is a safe and superior alternative to AADs for maintenance of sinus rhythm.¹¹ However, the safety and efficacy of CA in elderly patients with AF have been questioned. Several cardiologists have doubts about offering ablation to elderly patients due to fear of complications.

The present study sought to evaluate the rate of complications of CA for AF across various age groups.

Between April 2016 and April 2020, we evaluated 219 patients who underwent AF ablation. Table 1 shows the demographic characteristics and comorbidities of the patients. The majority of the patients were men (73.1%), white (73.1%), and older than 60 years (58.4%; median age: 63 [54 to 71] years). The group > 70 years of age represented 26.5% of the total patients; 32% of the patients were between 60 and 70 years of age; 41.6% were under the age of 60 years, and 10 patients were octogenarians. Approximately one third of the patients were overweight. A history of hypertension was documented in 64.7% of the patients, diabetes mellitus in 19.8%, stable coronary artery disease in 19.1%, and a previous history of stroke or transient ischemic attack in 10.5%. All the patients demonstrated a normal left ventricular ejection fraction and a mean left atrial diameter of 43 mm (38 to 48 mm). The median CHA₂DS₂-VASc score was 2 (1 to 4), and 70.7% had a score higher than 2. Most of the patients (63.8%) presented with paroxysmal AF; 21.6% had persistent AF for less than 1 year, and 14.6% of the patients had long-standing persistent AF. The medications used are presented in Table 2.

Table 1

	N	Total	< 60 years	60 – 70 years	> 70 years	P
Age, years	219	63.0 (54.0 – 71.0)	52.0 (46.0 – 57.0)a	66.0 (63.0 – 68.0)a	74.0 (72.0 – 79.0)a	0.000
Men, n (%)	219	160 (73.1)	74 (81.3)*	53 (75.7)	33 (56.9)*	0.004
White, n (%)	171	125 (73.1)	48 (66.7)	41 (75.9)	36 (80.0)	0.244
BMI, kg/m2	148	27.5 (24.8 – 30.1)	27.9 (23.9 – 30.5)	27.4 (25.1 – 30.1)	26.7 (24.2 – 29.9)	0.798
Obesity, n (%)	148	45 (30.4)	21 (33.3)	12 (27.3)	12 (29.3)	0.785
AF type	185					0.198
Paroxysmal, n (%)		118 (63.8)	55 (74.3)	35 (57.4)	28 (56.0)
Persistent < 1 year, n (%)		40 (21.6)	11 (14.9)	16 (26.2)	13 (26.0)
Persistent > 1 year, n (%)		27 (14.6)	8 (10.8)	10 (16.4)	9 (8.0)
AF time, months	162	14.0 (6.0 – 26.0)	14.0 (7.0 – 24.0)	19.0 (6.0 – 37.0)	10.0 (4.5 – 20.0)	0.046
Smoker	186	39 (21.0)	15 (19.5)	14 (25.0)	10 (18.9)	0.673
HTN, n (%)	184	119 (64.7)	38 (48.7)*	40 (71.4)	41 (82.0)*	0.000
Stroke/TIA, n (%)	181	19 (10.5)	4 (5.3)	6 (10.7)	9 (18.0)	0.077
Diabetes, n (%)	187	37 (19.8)	13 (16.5)	12 (21.1)	12 (23.5)	0.589
Heart failure, n (%)	186	25 (13.4)	9 (11.4)	9 (16.4)	7 (13.5)	0.709
CAD, n (%)	178	34 (19.1)	5 (7.0)*	8 (14.3)	21 (41.2)*	0.000
CKD, n (%)	184	5 (2.7)	0 (0.0)	2 (3.5)	3 (5.9)	0.123
OSA, n (%)	145	92 (63.4)	39 (65.0)	24 (54.5)	29 (70.7)	0.286
COPD, n (%)	167	9 (5.4)	1 (1.5)	6 (11.1)	2 (4.4)	0.061
Previous ECV, n (%)	155	84 (54.2)	24 (40.0)*	33 (64.7)	27 (61.4)	0.018
CHADS-VASc	188	2 (1 – 4)	1 (0 – 2)*	3 (2 – 3)*	4 (3 – 5)*	0.000
CHADS-VASc ≥ 2 , n (%)	188	133 (70.7)	31 (39.2)*	51 (87.9)*	51 (100)*	0.000
Echocardiogram
LA (mm)	157	43.0 (38.0 – 48.0)	41.0 (37.0 – 45.0) a	44.5 (40.0 – 49.2)	43.0 (38.0 – 48.0)	0.035
LVEF %	156	64.0 (56.0 – 69.0)	64.0 (59.0 – 68.0)	64.0 (50.0 – 69.0)	66.0 (55.8 – 70.0)	0.240
Thrombus at screening, n %	174	8 (4.6)	0 (0.0)*	3 (5.5)	5 (10.6)*	0.024

* Significant difference (adjusted residual). a Significant difference (Tamhane’s T2) versus other groups. AF: atrial fibrillation; BMI: body mass index; CAD: coronary artery disease; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; ECV: electrical cardioversion; HTN: hypertension; LA: left atrium; LVEF: left ventricular ejection fraction; N: number; OSA: obstructive sleep apnea; TIA: transient ischemic attack

Table 2

	N	Total	< 60 years	60 – 70 years	> 70 years	P
Amiodarone, n (%)	174	91 (52.3)	28 (38.9)*	32 (59.3)	31 (64.6)*	0.010
Propafenone, n (%)	176	52 (29.5)	26 (35.6)	17 (30.4)	9 (19.1)	0.153
Sotalol, n (%)	170	13 (7.6)	7 (9.9)	2 (3.8)	4 (8.7)	0.430
Betablocker, n (%)	170	69 (40.6)	25 (35.2)	25 (47.2)	19 (41.3)	0.404
Digoxin, n (%)	171	2 (1.2)	2 (2.8)	0 (0.0)	0 (0.0)	0.240
Verapamil/diltiazem, n (%)	171	3 (1.8)	1 (1.4)	0 (0.0)	2 (4.3)	0.246
ACE inhibitor/ARB, n (%)	170	74 (43.5)	28 (39.4)	21 (39.6)	25 (54.3)	0.223
Diuretics, n (%)	169	41 (24.3)	14 (20.0)	11 (20.8)	16 (34.8)	0.148
Dabigatran, n (%)	171	79 (46.2)	29 (40.3)	24 (45.3)	26 (56.5)	0.223
Rivaroxaban, n (%)	171	44 (25.7)	20 (27.8)	15 (28.3)	9 (19.6)	0.534
Apixaban, n (%)	171	31 (18.1)	14 (19.7)	10 (18.5)	7 (15.2)	0.823
Edoxaban, n (%)	175	12 (6.9)	7 (9.5)	2 (3.7)	3 (6.4)	0.440
Warfarin, n (%)	177	5 (2.8)	2 (2.7)	1 (1.9)	2 (4.0)	0.808
ASA, n (%)	186	14 (7.5)	6 (7.7)	6 (10.3)	2 (4.0)	0,459
Clopidogrel, n (%)	185	7 (3.8)	2 (2.6)	1 (1.7)	4 (8.0)	0,181

* Significant difference. ACE: angiotensin converting enzyme; ARB: angiotensin receptor blocker; ASA: acetylsalicylic acid; N: number.

The ablation characteristics and complications are presented in Tables 3 and 4. Most of the patients were in their first ablation (89.4%), and a PVI-only strategy was used as the most frequent procedure approach (57.1%), yielding an average of 68 minutes spent in the left atrium and 96 minutes as the total ablation time. An average of 86.2% of the patients had their esophagus monitored with a single-probe thermometer, and 44.7% of the patients had elevated temperature.

Table 3

	N	Total	< 60 years	60 – 70 years	> 70 years	P
First ablation, n (%)	189	169 (89.4)	69 (89.6)	55 (91.7)	45 (86.5)	0.677
Strategy	177					0.014
PVI only, n (%)		101 (57.1)	48 (69.6)	25 (43.9)	28 (54.9)	0.014
PVI plus lines, n (%)		76 (42.9)	21 (30.4)	32 (56.1)	23 (45.1)
LA total time (min),	152	68.0 (56.0 – 86.0)	70.0 (60.0 – 90.0)	66.0 (55.0 – 85.0)	66.5 (49.8 – 82.8)	0.206
Ablation total time (min),	154	96.0 (78.0 – 118.5)	98.0 (80.8 – 120.5)	91.0 (75.0 – 112.5)	96.0 (76.0 – 110.0)	0.368
Esophagus temperature probe	174	150 (86.2)	60 (84.5)	49 (87.5)	41 (87.2)	0.864
Esophageal temperature elevation	150	67 (44.7)	28 (46.7)	19 (38.0)	20 (50.0)	0.483
Total complications	219	10 (4.6)	3 (3.3)	4 (5.7)	3 (5.2)	0.742
Major complications	219	7 (3.2)	3 (3.3)	1 (1.4)	3 (5.2)	0.486
AF recurrence	142	12 (8.5)	5 (8.6)	3 (6.7)	4 (10.3)	0.839

AF: atrial fibrillation; LA: left atrium; N: number; PVI: pulmonary vein isolation.

Table 4

Patient	Age	Sex	Major complication	Minor complication
1	54	M	Vascular (surgical repair)	-
2	56	F	Pericardial tamponade	-
3	60	F	Diaphragmatic paralysis	-
4	66	M	-	Femoral hematoma
5	67	F	Pericardial tamponade	-
6	68	M	-	Femoral hematoma
7	69	F	-	Pseudoaneurysm
8	73	F	Stroke	-
9	80	F	Pericardial tamponade	Femoral hematoma
10	82	M	Pericardial tamponade	-

F: female; M: male.

During the follow-up, there were no cases of atrial-esophageal fistula or death. A total of 10 patients (4.6%) were observed to have complications. The type and characteristics of each patient with major or minor complications are described in Table 4.

The patients were classified according to age range as follows: 41.6% < 60 years, 32.0% between 60 and 70 years, and 26.5% > 70 years. Comparative analysis showed a higher prevalence of women, hypertension, coronary artery disease, previous electric cardioversion, presence of thrombus at screening, and higher CHA₂DS₂-VASc scores between the oldest groups (Table 1). Additionally, the patients aged > 70 years had a shorter time from the first diagnosis of AF to the ablation date.

Amiodarone use was more frequent among older adults (Table 2). No other differences were found in the demographics, comorbidities, or medications among the groups.

In Table 3, the PVI-only strategy was more common in the younger group. No other differences in the ablation procedure were observed between the groups. The frequency of major or minor complications did not differ between the groups (Table 3). The distribution of the complication rates by age is shown in Figure 1.

Figure 1

The study’s main finding was no significant differences in AF CA-related complications when comparing patients by age group, and the rate of complications obtained in this study was low.

AF is the most common arrhythmia in the elderly population; moreover, its prevalence is expected to increase exponentially over the following years.³This type of arrhythmia by itself is a strong independent factor for stroke, with a 5‐fold increased risk of thromboembolic events in patients of all ages, with up to 30% of cerebrovascular accidents in the elderly being attributed to AF.⁴

The management of patients with AF can be divided into rate control or rhythm control strategies. Elderly patients frequently benefit from rate control; however, there is a subset of patients who can become very symptomatic. As such, a rhythm control strategy might be a reasonable option upfront. Given the high prevalence of comorbidities in this population, the use of AAD might pose a particular challenge and increase the incidence of side effects; therefore, CA for AF can become a reasonable treatment, as it has been shown to be more effective than AAD in maintaining sinus rhythm as well as improving functional status and quality of life.^11,12 However, current studies show that the safety of this procedure in the elderly population is somewhat controversial.

Some studies indicate that there is no evidence of an increased risk of major complications in older patients.^12-15 Moreover, a retrospective study with a large group of 86,119 patients, 3,482 of whom were octogenarians, with AF ablation as the primary diagnosis, examined the outcomes including mortality, and concluded that there was no significant difference in the mortality outcomes between the octogenarian population and those aged less than 80 years.¹⁶

On the contrary, other studies showed relatively higher vascular bleeding complications, both acutely (4%) and within 30 days after the procedure (2.6%).¹⁷ For instance, one group observed a total of 137 procedures in a population of subjects older than 75 years of age, with 8 major (5.8%), and 26 minor (19%) periprocedural complications.¹⁸ Another study reported a higher rate of complications in patients aged ≥ 70 years than in the younger population (6.7% versus 1.0 %, P < 0.001). The most worrisome complication was the increased rate of periprocedural stroke (3.3% versus 0.7%, P = 0.058).¹⁹ Our analyses showed very low incidence of stroke (1 patient). The reasons for the reported difference in procedure-related complications are unclear and may be multifactorial, including the risk profile of each patient, anticoagulation management, and different ablation techniques and tools. Aging is associated with aortic stiffening, myocardial hypertrophy, myocardial fibrosis, and frequently, cardiac amyloidosis. The complex interactions between the cardiovascular aging process and cardiovascular risk factors determine the left ventricular remodeling pattern.²⁰ It is controversial whether this aging process implies greater risk during the CA procedure.

It should be noted that aging is not a homogenous process. The myocardial aging process is determined by a balanced interaction between collagen, fibroblasts, cardiomyocytes, capillary vessels, and interstitial fibrosis. During the pathological aging process, the myocardium undergoes important tissue composition and remodeling changes (hypertrophy, interstitial and replacement fibrosis, and so on), causing myocardial frailty. A healthy aging process has a more balanced interaction between myocardial components without a predominance of fibrosis and fibroblasts. The aging process is genetically programmed, but it is modified by environmental influences, with the result that the rate of aging can vary widely among people. Therefore, it is controversial whether exclusively the aging process implies higher risk during the CA procedure. Figure 2 illustrates the cardiovascular aging process.

Figure 2

We studied a group of patients with AF who underwent ablation, separated into 3 groups by age to evaluate procedural safety. The oldest group presented higher prevalence of hypertension and coronary artery disease, higher CHA₂DS₂-VASc scores (all patients > 2), and a higher incidence of thrombus at screening in comparison to the other 2 groups.

The incidence of thrombus at screening before ablation was higher in the group ≥ 70 years. As the presence of thrombus was higher in the oldest group, the occurrence of stroke would have higher chances; however, a low incidence was observed, with only 1 case reported and no difference in the rate of serious cerebrovascular and cardiac complications in the elderly patients, despite a significantly higher thromboembolic risk. All the patients underwent ablation with anticoagulation therapy.

The total ablation time and time spent in the left atrium were similar between the groups; however, in the younger group, the PVI-only approach was higher, possibly because of the higher prevalence of paroxysmal AF and less atrial disease extension. Despite the high-power energy delivery, only 45% exhibited esophageal temperature elevation, and no patient had atrial-esophageal fistula during the follow-up; additionally, there were no complications directly related to the radiofrequency applications. Of the total of 7 major complications, 4 were due to cardiac tamponade: 1 in the group < 60 years, 1 in the group 60 to 70 years, and 2 in the group over 70 years. The other 3 major complications were due to vascular injury with surgical correction, stroke, and diaphragmatic paralysis, and only 1 of these was in the older group. The low incidence of complications, as well as the small sample of patients, may be responsible for the lack of statistical significance in this comparison of groups.

The total complication rates in our patients were 3.3% (< 60 years), 5.7% (60 to 70 years), and 5.2% (> 70 years), without statistical difference. The major complications were also not statistically different between the groups, reaching a total of 3.2%. Additionally, no major complications had an impact on the functional status of the patients after hospital discharge. All major and minor complications were completely resolved during hospitalization, and no patient died due to the procedure. Despite a high-power energy delivery, no complications were directly related to the radiofrequency applications.

Not all elderly patients are the same; therefore, the ablation strategy can change. For instance, previous research concluded that octogenarians referred for CA of AF were more frequently women, with a higher rate of associated comorbidities and more frequent non-pulmonary vein triggers; therefore, more ablation was needed.²¹ However, more data are necessary to better understand the main predictors of AF ablation complications. Our study included a population with fewer comorbidities, predominantly composed of patients with paroxysmal AF; hence, PVI-only ablation was the most frequent approach. Careful patient selection is crucial.

Importantly, whether the safety of CA for AF in elderly patients could be generalized to all institutions (high or low-volume centers) or to less experienced operators warrants further investigation. According to a recent meta-analysis,²² there is an inverse relationship between both the hospital and operators of AF ablation volume and the incidence of complications. Hospitals performing ≥ 50 procedures/year demonstrated significantly lower mortality compared with those performing < 50 procedures/year (0.16% versus 0.55%, odds ratio = 0.33, 95% confidence interval 0.26 to 0.43, P < 0.001. A similar relationship existed between an operator experience volume of < 50 procedures/year and the incidence of complications (3.75% versus 12.73%, P < 0.001; odds ratio = 0.27, 95% confidence interval 0.23 to 0.32).²¹ Our team performed more than 100 AF ablations in 2020 and is in accordance with the current evidence with low complication rates independent of patient age, thus leading us to question whether age is a determinant variable for ablation complications in not very elderly patients.

Elderly populations are more sensitive to the impacts of both disease and treatment; therefore, medical decisions are more difficult. Cardiac aging is characterized by a series of complex events of ventricle and valvular changes identified at structural, cellular, molecular, and functional levels, making the aged myocardium more susceptible to stress and leading to a high prevalence of cardiovascular diseases in the elderly population.²⁰ Our data analysis, for our demographic patient and procedure profile, indicates that AF ablation might be a good treatment without adding additional risk than the disease itself, thereby raising the hypothesis that the benefit of offering ablation for sinus rhythm maintenance outweighs the risk of AF. Figure 3 illustrates an AF ablation guided by a 3D electroanatomic mapping system.

Figure 3

The AF CA treatment demonstrated no significant differences in procedure-related complications when comparing patients by age group. The rate of the general complications obtained in this study was low, which may suggest that CA is a safe procedure in elderly patients.