Virtual sleep disordered-breathing management in the work-up of patients with atrial fibrillation: treatment initiation and trajectory within the Virtual-SAFARI study

Abstract Background Sleep disordered breathing (SDB) is highly common in patients with atrial fibrillation (AF). Accurate detection and treatment of SDB are essential to improve ablation outcomes for these patients. Purpose We present the SDB treatment initiation and trajectory follow-up results from our previously implemented virtual sleep apnoea management pathway (Virtual-SAFARI) in patients with AF. Methods Consecutive patients with AF who were scheduled for AF ablation were prospectively included. Patients were digitally referred to a virtual sleep apnoea screening and management pathway which, in brief, included an overnight home sleep test and initiation of SDB treatment at the patients’ homes, if necessary. SDB diagnosis was based on apnoea-hypopnea index (AHI), categorized as none-to-mild SDB for AHI <15 and moderate-to-severe SDB for AHI ≥ 15. Results A total of 396 patients were analyzed (38.4% female, median 64 [58-70] years old). Within a median time to SDB diagnosis of 11 days, a total of 196 (49.5%) patients were newly diagnosed with moderate-to-severe SDB and 200 (50.5%) with none-to-mild SDB. Of those with moderate-to-severe SDB, 174 patients (88.8%) received SDB treatment, with a total of 90 (45.9%) patients with positive airway pressure (PAP) therapy, 65 (33.2%) with mandibular repositioning appliances (MRA), and 19 (9.7%) with sleep position training (SPT). Median PAP compliance was 5:50 hours per night (3:44 – 6:55 hours). Amongst overall 231 patients who received SDB treatment (including 57 with none-to-mild SDB), in 23 (10.0%) patients treatment was stopped and in 33 (14.3%) SDB treatment was further adapted. Median time between SDB diagnosis and ablation was 66 (28-120) days and median time between SDB treatment and ablation was 6 days (40 days prior to ablation to 73 days after ablation). Median time to ablation was longer in patients with moderate-to-severe SDB compared to none-to-mild SDB (82 [48-157] days vs 61 [33-95] days, p < 0.001). During the ablation, patients with moderate-to-severe SDB were more likely to receive general anesthesia for AF ablation compared to patients with none-to-mild SDB (83 [58.0%] vs 23 [16.2%] p < 0.001). Significant differences in receiving general anesthesia were also observed between SDB treatment and no-treatment groups (84 [51.5%] vs 22 [18.0%] p<0.001) as well as among treatment modalities (PAP: 43 [67.2%], MRA: 30 [40.5%], SPT 11 [44.0%], p=0.005). Conclusions In patients scheduled for AF ablation, a virtual sleep apnoea management pathway (Virtual-SAFARI) lead to new diagnosis of moderate-to-severe SDB in almost half of patients, which triggers the initiation of new SDB treatments. Patients with moderate-to-severe SDB were more likely to receive general anesthesia for AF ablation and had a significantly longer time to ablation. Future research will be performed on the impact of SDB therapy on AF ablation outcomes.