NT-proBNP as a predictor of successful pulmonary vein isolation using pulsed-field, cryoballoon or radiofrequency ablation

Abstract Background B-Type natriuretic peptide (NT-proBNP) is recognized as a biomarker for atrial disease as well as a predictor for the success of pulmonary vein isolation (PVI). In recent years pulsed-field ablation (PFA) has emerged as a novel technology for performing PVI. Purpose Previous studies have shown a correlation between NT-proBNP levels and atrial fibrillation recurrence following PVI using radiofrequency ablation (RFA) and cryoballoon ablation (CBA). This study aims to investigate whether NT-proBNP can also serve as a reliable predictor for successful PVI using pulsed-field ablation (PFA). Additionally, we aim to analyse the predictive strength of NT-proBNP for successful PVI. Methods From our prospective atrial fibrillation ablation registry, we included all patients who underwent primary PVI using either RFA (n=302), CBA (n=399) or PFA (n = 527) during the study period from May 2018 to December 2023. Follow-up assessments were conducted with 7-day Holter ECGs at 3, 6 and 12 months post-procedure. Any additional records of atrial fibrillation (AF) recurrence from other clinical settings were also included as endpoints. Baseline NT-proBNP was measured before PVI. We applied the standard 95th percentile cut-off, adjusted for age and sex in healthy adults, as the NT-proBNP threshold. For predictive modelling, NT-proBNP values were converted into multiples of the respective 95th percentile and log-transformed. Statistical analysis were conducted using log-rank or Mantel-Haenszel test, and Cox proportional hazard models were applied as appropriate. Results Overall, 576/1228 patients (47%) showed elevated NT-proBNP levels before PVI. The 1-year recurrence-free survival, using the adjusted 95th percentile as a cut-off for NT-proBNP, demonstrated similar predictive strength across all ablation technologies (RFA: 74% vs 55%, p < 0.001; CBA: 81% vs 58%, p < 0.001; PFA: 78% vs 57%, p < 0.001; Figure 1). In a Cox proportional hazards model to predict 12-month recurrence-free survival, we included converted NT-proBNP, sex, age, left atrial volume index (LAVI), and type of AF as covariates. NT-proBNP and type of AF were the only significant predictors of recurrence-free survival, with NT-proBNP being most significant (NT-proBNP: p < 0.0005; type of AF: p < 0.005; sex: p =0.28; age: p = 0.34; LAVI: p=0.07). A second Cox proportional hazard model for recurrence-free survival, fitted only for converted NT-proBNP and type of atrial fibrillation, was used to develop a color-coded survival probability chart (Figure 2). Conclusions NT-proBNP is a reliable and independent predictor for recurrence-free survival following primary PVI, regardless of the ablation technology used. It outperforms other parameters in predicting recurrence-free survival. A color-coded survival probability chart, incorporating NT-proBNP and type of AF, may aid in collaborative, well-informed decision-making with the patient.