This primary analysis within a large retrospective, international study aimed to evaluate the long-term outcomes of catheter ablation for atrial fibrillation in octogenarian vs. non-octogenarian patients. Among patients with paroxysmal and non-paroxysmal atrial fibrillation receiving a catheter-based therapy, age over 80 was associated with significantly higher atrial arrhythmia recurrence rates throughout 365 days of follow-up. Notably, the median follow-up duration was considerably shorter in the octogenarian group, which contributes to the less marked apparent difference in the raw event numbers observed.

The disparity in long-term success rates of catheter ablation among octogenarians can be attributed to several factors. This age group typically presents with a higher prevalence of comorbidities and established risk factors for atrial fibrillation, implying a greater likelihood of atrial scarring and a pro-arrhythmic substrate [18, 19]. Additionally, the presence of extra-pulmonary atrial fibrillation triggers have been shown to be more common in octogenarians [20, 21]. Notably, continuous rhythm monitoring with an indwelling permanent pacemaker, ICD, or ILR was more common among octogenarians, and one might expect this to explain the higher detection rates of atrial arrhythmia within this age group [22]. Nevertheless, in a multivariable model for predicting the recurrence of atrial arrhythmia demonstrated that age over 80 was an independent predictor of recurrence, while the presence of an indwelling permanent pacemaker, ICD, or ILR at the time of the procedure was not.

Additionally, the demographic analysis revealed a predominance of females in the octogenarian group. This gender difference may be explained by the generally higher life expectancy and relatively better health status of females, making them more likely to undergo interventions at older age.

The procedural complication rate was higher in octogenarians compared to younger patients. The main complications observed were related to vascular access, bleeding, and cardiac tamponade. These complications are more common in older adults due to increased frailty and comorbidities.

In our multivariable analysis, several factors such as age over 80 and previous AF ablation were independent predictors of AF recurrence. Although type of AF (paroxysmal vs. non-paroxysmal) was considered in our analyses, it did not independently predict AF recurrence, indicating that other factors may play a more significant role in recurrence risk among octogenarians.

This study substantiates and builds upon previous research regarding atrial fibrillation ablation in patients over 80. [9, 11,12,13,14, 23, 24] Previous trials, while informative, involved a relatively small number of octogenarian patients. These studies suggested comparable long-term outcomes regarding arrhythmia recurrence among octogenarians and non-octogenarians. However, due to the limited sample size in these studies, comparisons should be made with care, as neutral results could be partially attributed to a lack of statistical power. A prior meta-analysis suggested limited efficacy of AF ablation in patients over 75, but due to insufficient statistical power and data inconsistency within the octogenarian group, no specific conclusions could be drawn for this age group. [25]

Importantly, this study is the first of its kind, being a large, multicentre, international cohort exploring the outcomes of AF ablation in octogenarian vs. non-octogenarian patients. It not only examined a representative sample of both octogenarian and non-octogenarian patients but also considered recent advances in catheter ablation technology.

However, the study also bears some limitations. Primarily, the results are particular to octogenarians deemed suitable for PVI. The sample size also varied substantially across different participating centres, reflecting diverse eligibility criteria and thresholds for performing AF ablation in octogenarians across different hospitals. Further prospective studies are warranted to clarify the selection criteria for this age group. Despite efforts to minimise confounding factors through matching and multivariable regression analyses, some confounders may still exist. In a small subset of both octogenarians and non-octogenarians, arrhythmia recurrence was identified through typical symptoms reported and the treating physician’s judgement. While introducing a subjective element, the few recurrences diagnosed by this criterion did not affected the study’s overall findings as demonstrated in the sensitivity analyses that excluded these patients. One significant limitation of this study is the shorter median follow-up duration in the octogenarian group compared to the control group, with the follow-up period being approximately 20% shorter for octogenarians. This difference in follow-up duration is due to routine clinical follow-up procedures in observational settings, which could lead to shorter follow-up times in older patients who might have more frequent health issues or mobility constraints affecting their adherence to follow-up schedules. Although Cox regression and Kaplan–Meier analyses were used, employing censoring to deal with patients lost to follow-up, the shorter follow-up may still introduce bias by potentially underestimating the recurrence rates of atrial arrhythmia in this age group. To mitigate this bias, future prospective studies should strive to match follow-up durations more closely between age groups, ensuring more accurate comparisons. Despite this limitation, the higher observed recurrence rates in octogenarians are consistent with clinical expectations, suggesting that even with longer follow-up, the increased recurrence in older patients would likely persist. Additionally, potential selection bias should be considered. Octogenarians selected for catheter ablation in this study may have fewer comorbidities compared to the broader octogenarian population, which could limit the generalizability of our findings. Furthermore, while this manuscript provides an overview of procedural complications, a detailed examination of these complications is beyond the scope of the current analysis focused on long-term outcomes. A separate, in-depth analysis of the short-term outcomes and safety of AF catheter ablation in octogenarians is warranted to fully address the procedural risks associated with this intervention. This study predated the advent of Pulsed Field Ablation (PFA). Data was collected during a period of considerable advancements in cardiac ablation technology. Although technological diversity may have affected our findings, technological advancements should have similarly impacted the outcomes of both octogenarians and younger controls. Notably, beyond arrhythmia recurrence rates, the effect of AF on of cardiac function and quality of life in octogenarians must be addressed in future research. Importantly, while the primary outcome focuses on arrhythmia recurrence rates, the broader implications of AF ablation on cardiac function and quality of life in octogenarians warrant further investigation. Despite observing higher recurrence rates, AF ablation demonstrated favourable outcomes in this age group. Future research is needed to evaluate its impact on quality of life and patient-reported outcomes, particularly when comparing catheter ablation to the use of antiarrhythmic drugs, in octogenarians mostly limited to amiodarone, which is noted for its challenging safety and tolerance profile in this frail patient population.

In summary, our large international study comparing the outcomes of octogenarians vs. non-octogenarians undergoing catheter ablation for AF suggests that octogenarians experience higher recurrence rates of atrial arrhythmia and the potential causes behind this are multifactorial and need further study. Despite this, the long-term success rates for octogenarian patients are promising, affirming that AF ablation can be an effective treatment option for select individuals within this age group. Future research should focus on further refining patient selection criteria for this procedure in the octogenarian population, considering individual patient risk factors and the potential for improved quality of life and patient reported outcomes.