Heart, Lung and Circulation
Original Article| Volume 32, ISSUE 2, P205-214, February 2023

Catheter Ablation for Paroxysmal Atrial Fibrillation With Sick Sinus Syndrome: Insights From the Kansai Plus Atrial Fibrillation Registry

Published:October 20, 2022DOI:


      Coexisting sick sinus syndrome (SSS) is associated with both electrical and structural atrial remodelling in patients with atrial fibrillation (AF). Limited data are available concerning catheter ablation (CA) for AF in this condition. This study investigated the efficacy of CA as a curative therapy for AF and SSS in a large-scale prospective multicentre registry.


      The Kansai Plus Atrial Fibrillation (KPAF) registry enrolled 5,010 consecutive patients who underwent CA for AF; this included 3,133 patients with paroxysmal AF (mean age, 66 years; male, 69.3%; mean CHA2DS2-VASc score, 2.05±1.50; SSS, n=315 [tachy-brady syndrome, n=285]). The endpoints included the recurrence of AF with a blanking period of 90 days after CA, and de novo pacemaker implantation during the follow-up period (median duration, 2.93 years).


      The AF-free survival did not significantly differ between patients with and those without SSS (n=2,818) after the initial (log-rank p=0.864) and final sessions (log-rank p=0.268). Pacemakers were implanted in 48 patients with SSS, and implantation in this group was significantly associated with AF recurrence, including early recurrence (adjusted odds ratio, 3.57; 95% confidence interval, 1.67–7.64; p=0.002). The remaining 85.3% of patients with SSS did not require pacemaker implantation at 3 years after CA.


      Coexisting SSS did not adversely affect recurrence-free survival after CA for paroxysmal AF. Pacemaker implantation was not required in most patients with SSS, with AF recurrence serving as a strong predictor for this.


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        • Kusumoto F.M.
        • Schoenfeld M.H.
        • Barrett C.
        • Edgerton J.R.
        • Ellenbogen K.A.
        • Gold M.R.
        • et al.
        2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society.
        J Am Coll Cardiol. 2019; 74: 932-987
        • John R.M.
        • Kumar S.
        Sinus node and atrial arrhythmias.
        Circulation. 2016; 133: 1892-1900
        • Chang W.
        • Li G.
        Clinical review of sick sinus syndrome and atrial fibrillation.
        Herz. 2022; 47: 244-250
        • Kottkamp H.
        Fibrotic atrial cardiomyopathy: a specific disease/syndrome supplying substrates for atrial fibrillation, atrial tachycardia, sinus node disease, AV node disease, and thromboembolic complications.
        J Cardiovasc Electrophysiol. 2012; 23: 797-799
        • Hocini M.
        • Sanders P.
        • Deisenhofer I.
        Jaïs P, Hsu LF, Scavée C, et al. Reverse remodeling of sinus node function after catheter ablation of atrial fibrillation in patients with prolonged sinus pauses.
        Circulation. 2003; 108: 1172-1175
        • Hindricks G.
        • Potpara T.
        • Dagres N.
        • Arbelo E.
        • Bax J.J.
        • Blömstrom-Lundqvist C.
        • et al.
        2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.
        Eur Heart J. 2021; 42: 373-498
        • Calkins H.
        • Hindricks G.
        • Cappato R.
        • Kim Y.H.
        • Saad E.B.
        • Aguinaga L.
        • et al.
        2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary.
        J Arrhythm. 2017; 33: 369-409
        • Nogami A.
        • Kurita T.
        • Abe H.
        • Ando K.
        • Ishikawa T.
        • Imai K.
        • et al.
        JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias.
        J Arrhythm. 2021; 37: 709-870
        • Hayashi K.
        • Fukunaga M.
        • Yamaji K.
        • An Y.
        • Nagashima M.
        • Hiroshima K.
        • et al.
        Impact of catheter ablation for paroxysmal atrial fibrillation in patients with sick sinus syndrome - important role of non-pulmonary vein foci.
        Circ J. 2016; 80: 887-894
        • Chen Y.W.
        • Bai R.
        • Lin T.
        • Salim M.
        • Sang C.H.
        • Long D.Y.
        • et al.
        Pacing or ablation: which is better for paroxysmal atrial fibrillation-related tachycardia-bradycardia syndrome?.
        Pacing Clin Electrophysiol. 2014; 37: 403-411
        • Inada K.
        • Yamane T.
        • Tokutake K.I.
        • Yokoyama K.I.
        • Mishima T.
        • Hioki M.
        • et al.
        The role of successful catheter ablation in patients with paroxysmal atrial fibrillation and prolonged sinus pauses: outcome during a 5-year follow-up.
        Europace. 2014; 16: 208-213
        • Kobori A.
        • Shizuta S.
        • Inoue K.
        • Kaitani K.
        • Morimoto T.
        • Nakazawa Y.
        • et al.
        Adenosine triphosphate-guided pulmonary vein isolation for atrial fibrillation: the UNmasking Dormant Electrical Reconduction by Adenosine TriPhosphate (UNDER-ATP) trial.
        Eur Heart J. 2015; 36: 3276-3287
        • Kaitani K.
        • Inoue K.
        • Kobori A.
        • Nakazawa Y.
        • Ozawa T.
        • Kurotobi T.
        • et al.
        Efficacy of antiarrhythmic drugs short-term use after catheter ablation for atrial fibrillation (EAST-AF) trial.
        Eur Heart J. 2016; 37 (610–8)
        • Tanaka N.
        • Inoue K.
        • Kobori A.
        • Kaitani K.
        • Morimoto T.
        • Kurotobi T.
        • et al.
        Sex differences in atrial fibrillation ablation outcomes: insights from a large-scale multicentre registry.
        Europace. 2020; 22 (1345–57)
        • Khaykin Y.
        • Marrouche N.F.
        • Martin D.O.
        • Saliba W.
        • Schweikert R.
        • Wexman M.
        • et al.
        Pulmonary vein isolation for atrial fibrillation in patients with symptomatic sinus bradycardia or pauses.
        J Cardiovasc Electrophysiol. 2004; 15: 784-789
        • Akoum N.
        • McGann C.
        • Vergara G.
        • Badger T.
        • Ranjan R.
        • Mahnkopf C.
        • et al.
        Atrial fibrosis quantified using late gadolinium enhancement MRI is associated with sinus node dysfunction requiring pacemaker implant.
        J Cardiovasc Electrophysiol. 2012; 23: 44-50
        • Marrouche N.F.
        • Wilber D.
        • Hindricks G.
        • Jais P.
        • Akoum N.
        • Marchlinski F.
        • et al.
        Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study.
        JAMA. 2014; 311: 498-506
        • Wong G.R.
        • Nalliah C.J.
        • Lee G.
        • Voskoboinik A.
        • Chieng D.
        • Prabhu S.
        • et al.
        Sex-related differences in atrial remodeling in patients with atrial fibrillation: relationship to ablation outcomes.
        Circ Arrhythm Electrophysiol. 2022; 15e009925
        • Kim D.H.
        • Choi J.I.
        • Lee K.N.
        • Ahn J.
        • Roh S.Y.
        • Lee D.I.
        • et al.
        Long-term clinical outcomes of catheter ablation in patients with atrial fibrillation predisposing to tachycardia-bradycardia syndrome: a long pause predicts implantation of a permanent pacemaker.
        BMC Cardiovasc Disord. 2018; 18: 106
        • Onishi N.
        • Kaitani K.
        • Nakagawa Y.
        • Inoue K.
        • Kobori A.
        • Nakazawa Y.
        • et al.
        The association between late-phase early recurrence within the blanking period after atrial fibrillation catheter ablation and long-term recurrence: insights from a large-scale multicenter study.
        Int J Cardiol. 2021; 341: 39-45
        • Cochet H.
        • Mouries A.
        • Nivet H.
        • Sacher F.
        • Derval N.
        • Denis A.
        • et al.
        Age, atrial fibrillation, and structural heart disease are the main determinants of left atrial fibrosis detected by delayed-enhanced magnetic resonance imaging in a general cardiology population.
        J Cardiovasc Electrophysiol. 2015; 26: 484-492