Body Roundness Index as a Predictor of Electrical Cardioversion Failure in Patients With Persistent Atrial Fibrillation

ABSTRACT Background Electrical cardioversion (ECV) is a commonly performed procedure for rhythm control in patients with atrial fibrillation (AF); however, approximately 10%–15% of procedures are unsuccessful. Although several clinical and echocardiographic predictors of ECV success have been identified, the impact of the Body Roundness Index (BRI) on ECV outcomes has not yet been clearly established. In this study, we aimed to investigate the effect of BRI on post‐procedural ECV success in patients undergoing cryoballoon ablation for persistent AF. Methods This retrospective study included patients who underwent cryoballoon ablation for persistent AF between January 2024 and December 2025 at the Electrophysiology Unit of the Cardiology Department, Etlik City Hospital, Ministry of Health of the Republic of Türkiye. Following cryoballoon ablation, electrical cardioversion was performed to restore sinus rhythm. Patients were divided into two groups according to cardioversion outcome: successful and unsuccessful ECV. A total of 419 patients were screened; 160 patients with paroxysmal AF and 10 patients with incomplete anthropometric or echocardiographic data were excluded. Ultimately, 249 patients were included in the final analysis. Results Among the 249 patients included in the study, sinus rhythm was successfully restored in 201 patients (80.7%) following the standard ECV protocol, whereas ECV failed in 48 patients (19.3%). Patients in the unsuccessful ECV group had significantly higher BRI values compared with those in the successful group (6.23 ± 1.17 vs. 4.08 ± 0.73, p < 0.001). Similarly, body mass index (BMI) was also significantly higher in the unsuccessful group (30.95 ± 3.45 vs. 29.16 ± 3.39, p = 0.001). In addition, patients with unsuccessful ECV had larger left atrial diameter (48.88 ± 5.10 mm vs. 42.31 ± 4.65 mm, p < 0.001) and lower ejection fraction values (49.33 ± 13.38% vs. 54.60 ± 9.34%, p = 0.002). In multivariable logistic regression analysis, BRI emerged as a strong and independent predictor of ECV failure (OR = 29.363, 95% CI: 8.102–106.423, p < 0.001). Receiver operating characteristic (ROC) curve analysis demonstrated that BRI had superior discriminative performance compared with BMI in predicting ECV failure (AUC = 0.972, 95% CI: 0.952–0.992). The optimal BRI cutoff value for predicting ECV failure was 4.94, with a sensitivity of 93.8% and specificity of 89.5%. In contrast, the BMI cutoff value was 30.95 kg/m 2 , yielding a sensitivity of 45.8% and specificity of 77%. Conclusion Body Roundness Index appears to be a stronger anthropometric predictor than BMI for predicting electrical cardioversion failure in patients with persistent atrial fibrillation.