Advanced TecHnologies for succEssful ablationN of Atrial fibrillation in clinical practice (The ATHENA Study)

Background: Atrial fibrillation (AF) is the most common arrhythmia treated with catheter ablation, yet recurrence remains a significant challenge. The ATHENA study aims to identify clinical and procedural predictors of AF recurrence after ablation, with a focus on the 4S-AF (Stroke risk, Symptom severity, Severity of AF burden, Substrate severity) scheme. Methods: In this study, 402 consecutive patients undergoing AF ablation at an Italian referral center were prospectively enrolled between December 2021 and July 2023. Baseline clinical characteristics, procedural data, and follow-up outcomes were collected. Success was defined as freedom from AF recurrence at 12 months, excluding early recurrences within the first 3 months (blanking period). Follow-up included ECG and 24-hour Holter monitoring at 3, 6, and 12 months. Univariate and multivariate analyses were performed to identify significant predictors of AF recurrence Results: The mean age was 63.0 ± 9.9 years, and 71.4% were male. Paroxysmal AF was present in 61.9% of patients. At follow-up, 318 patients (79.1%) were free from AF recurrence (85.1% in paroxysmal AF, 69.3% in persistent AF, p < 0.001). Univariate analysis revealed that persistent AF, left atrial volume index (LAVi) >45 ml/m², ablation performed more than one year after AF onset, and AF at presentation were all significantly associated with recurrence. In multivariate analysis, the independent predictors of recurrence were LAVi >45 ml/m² (OR 2.6, 95% CI 1.53-4.42, p < 0.001), ablation after 1 year (OR 2.11, 95% CI 1.06-4.21, p = 0.034), and AF at presentation (OR 1.98, 95% CI 1.15-3.39, p = 0.013). The LUCA score, which incorporates these three factors, demonstrated moderate predictive accuracy (AUC: 0.679). Conclusions: The ATHENA study identified key predictors of AF recurrence, with left atrial volume index, timing of ablation, and AF at presentation being the most significant. The novel LUCA score provides a practical tool for stratifying patients by recurrence risk, enabling personalized treatment strategies. Early ablation and management of atrial remodeling are critical to improving long-term outcomes in AF patients.