Efficacy of catheter ablation in patients with persistent atrial fibrillation on chronic ibrutinib therapy
Authors: Pierucci N , La Fazia V M , Gianni C , Della Rocca D G , Mohanty S , Torlapati P G , Mariani M V , Burkhardt J D , Horton R P , Al-Ahmad A , Chimenti C , Di Biase L , Lavalle C , Natale A 
Published: May 2024

Abstract

Background
Ibrutinib represents a cornerstone in the management of B-Cells malignancies and chronic lymphatic leukaemia. This drug however was associated with a 5-fold increased risk of developing atrial fibrillation (AF). The consequences of AF in this category of frailty patients such as heart failure may lead to the need of Ibrutinib withdrawal, which is considered a disease modifying therapy.

Purpose
This study aims to evaluate the safety and efficacy of catheter ablation in managing AF in patients on chronic ibrutinib therapy.

Methods
this study evaluated 20 consecutive patients from two centres in Italy who developed persistent AF during chronic therapy with Ibrutinib for chronic lymphatic leukaemia or small lymphocytic lymphoma and underwent AF catheter ablation from 2016 to 2020. Antiarrhythmic drugs were withdrawn because of side effects and drug interaction. All receive pulmonary vein (PV) isolation + isolation of left atrial posterior wall (PW) and superior vena cava. A standardized protocol was performed to confirm persistent PVI and elicit any triggers originating from non-PV sites. Ablation of non-PV sites triggering runs of atrial tachyarrhythmias was left to operator's discretion. Exclusion criteria were age&lt;18 years and history of AF before ibrutinib therapy. Patients were monitored for arrhythmia at quarterly office visits, ECGs, 7-day Holter monitoring and event recorders during the first year followed by biannual checkups during the remaining part of the follow-up period.

Results
12 patients received PV+PW+SVC isolation plus ablation of non-PV trigger (Group 1) whereas 8 receive only PV+PW+SVC isolation (Group 2). 10 (83,3%) patients in group 1 remained arrhythmia-free without the need for additional antiarrhythmic drugs while only 3 (37,5%) in group 2 maintained sinus rhythms. Non pulmonary triggers were mostly found in left atrial appendage (5/12, 41,6%), coronary sinus (4/12, 33,3%) and crista terminalis (3/12 25%). More than one trigger was found in 4 (33.3) patients. After 22.3 ±3.6 months follow-up, patients with ablation of induced non-PV triggers had a significantly higher arrhythmia control than those whose triggers were not ablated (Chi – square p value: 0.035; Log rank p value: 0.014) (Fig.1). 5 patient that received left atrial appendage isolation underwent a left atrial appendage closure with Watchman device 3 months after atrial fibrillation ablation.

Conclusion
Catheter ablation in this category of patients seems to be a safe and effective tool for managing atrial fibrillation in patients with persistent AF on chronic ibrutinib therapy; an ablation strategy that includes as a first line therapy non pulmonary vein triggers appears to be an effective approach when compared to pulmonary vein plus posterior wall only. This approach will allow continuation of ibrutinib treatment, which markedly enhances the prognosis and diminishes the risk of adverse cardiovascular events in this patient population.Kaplan-Meier curve showing recurrence-fr