Predictors of nonpulmonary vein triggers for atrial fibrillation: A clinical risk score

Background Targeting non-pulmonary vein triggers (NPVTs) after pulmonary vein isolation may reduce atrial fibrillation (AF) recurrence. Isoproterenol infusion and cardioversion of spontaneous or induced AF can provoke NPVTs but typically require vasopressor support and increased procedure time. Objective To identify risk factors for the presence of NPVTs and create a risk score to identify higher-risk subgroups. Methods Using AF ablation registry at the Hospital of the University of Pennsylvania, we included consecutive patients who underwent AF ablation between January 2021 and December 2022. We excluded patients who did not receive NPVT provocation testing after failing to demonstrate spontaneous NPVTs. NPVTs were defined as non-pulmonary vein ectopic beats triggering AF or focal atrial tachycardia. We used risk factors associated with NPVTs with p-value<0.1 in multivariable logistic regression model to create a risk score in a randomly split derivation set (80%) and tested its predictive accuracy in the validation set (20%). Results In 1,530 AF ablations included, NPVTs were observed in 235 (15.4%). In derivation set, female sex (OR=1.40 [95%CI:0.96-2.03], p=0.080), sinus node dysfunction (OR=1.67 [95%CI:0.98-2.87], p=0.060), previous AF ablation (OR=2.50 [95%CI:1.70-3.65], p<0.001), and left atrial scar (OR=2.90 [95%CI:1.94-4.36], p<0.001) were risk factors associated with NPVTs. The risk score created from these risk factors (PRE2SSS2 score; [PRE]vious ablation:2 points, female [S]ex:1 point, [S]inus node dysfunction:1 point, left atrial [S]car:2 point) had good predictive accuracy in the validation cohort (AUC=0.728 [95%CI:0.648-0.807]). Conclusions A risk score incorporating predictors for NPVTs may allow provocation of triggers to be performed in patients with greatest expected yield.