Questioning the Role of Pulmonary Vein Isolation in Multimorbid Patients: A Prospective Analysis in Over 1,400 AF Patients.

Background: Early rhythm control (ERC) improves cardiovascular outcomes in patients with atrial fibrillation (AF) and a high comorbidity burden, but this benefit has been demonstrated primarily through antiarrhythmic drug therapy. It remains unclear whether catheter ablation - particularly pulmonary vein isolation (PVI) - achieves comparable efficacy in this high-risk population.

Objective: We aimed to assess the long-term effectiveness and safety of PVI in multimorbid AF patients.

Methods: We conducted a prospective, single-centre observational study of 1,402 consecutive patients undergoing first-time cryoballoon-based PVI. Patients were stratified by CHA₂DS₂-VA score; a score ≥4 defined high comorbidity burden. The primary endpoint was the recurrence of any atrial arrhythmia after a 90-day blanking period. Secondary endpoints included procedural safety and mortality.

Results: Over a mean follow-up of 2 years (range 6 months to 5 years), recurrence rates were significantly higher in patients with high vs. low comorbidity burden at 5 years (Kaplan-Meier event rates: 64.4% vs. 53.1%; HR 1.26; 95% CI 1.03-1.53; P=0.01). Age ≥75 years was the only independent predictor of recurrence. Safety outcomes and procedural safety were similar across groups.

Conclusion: Despite the established prognostic benefit of ERC in multimorbid patients, long-term rhythm control with PVI is significantly less effective in this population. These findings question routine first-line use of ablation-based strategies in patients most likely to benefit from rhythm control, highlighting the need for randomized trials comparing pharmacological and ablative ERC in high-risk AF cohorts.