Abstract 4147105: Risk Factors Associated with Non-Pulmonary Vein Triggers at First-Time Atrial Fibrillation Ablation

Background: The majority of non-pulmonary vein (PV) triggers of atrial fibrillation (AF) require provocative maneuvers for induction during catheter ablation. Identifying a subset of patients with higher likelihood of having non-PV triggers can guide more efficient use of these provocative maneuvers. Objective: This study aims to identify pre-procedural risk factors for the presence of non-PV triggers at first-time AF ablation. Methods: We included patients who underwent first-time AF ablation between 2019 and 2022 at the Hospital of the University of Pennsylvania. Non-PV trigger provocation maneuvers included cardioversion of AF if present at baseline, incremental isoproterenol (ISO) infusion (3-30mcg/min), and atrial burst pacing to induce focal atrial tachycardia (AT) or induce AF followed by cardioversion on 3-6mcg/min ISO or during high dose ISO washout. Non-PV triggers were defined as non-PV ectopic beats initiating AF or sustained focal AT. We used logistic regression analysis to identify pre-procedural risk factors associated with the presence of non-PV triggers. Risk factors with univariable p-value <0.2 were entered in a multivariable model. Results: Of 1805 patients with first-time AF ablation, 1701 (94.2%) patients that received non-PV trigger provocative maneuvers were included. A total of 146 (8.6%) patients were found to have non-PV triggers. The prevalence of non-PV triggers was numerically higher in patients with persistent AF than those with paroxysmal AF (9.7% vs 7.7%, p-value=0.163). In the multivariable model, female sex (OR=2.18, 95% CI: 1.49-3.17), cardiac sarcoidosis/amyloidosis (OR=7.29, 95% CI: 2.90-18.31), prior cardiac surgery (OR=2.30, 95% CI: 1.37-3.85), and moderate to severe left atrial enlargement on echocardiography (OR=2.66, 95% CI: 1.83-3.85) were independent predictors of non-PV triggers during first-time AF ablation. Conclusion: Non-PV triggers are present in approximately 10% of patients undergoing first-time AF ablation. A set of pre-procedural risk factors can risk stratify patients at high risk for non-PV triggers and guide choice of optimal ablation strategy at first procedure.