Evaluating Catheter Ablation in Atrial Fibrillation: Safety and Efficacy Across Different-Scale Medical Centers — A National Registry Analysis - The 72nd Annual Conference of the Israel Heart Society in association with the Israel Society of Cardiothoracic Surgery

Amer Dakka ¹ Eias Massalha Ibrahim Marai Yoav Michowitz Michael Glikson Yuval Konstantino Moti Haim David Luria Alexander Omelchenko Avishag Laish-Farkash Mahmoud Suleiman Eyal Nof Roy Beinart

¹Heart Institute, Sheba Medical Center
²Cardiology Department, Tzafon Medical Center, Israel
³Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Israel
⁴Department of Cardiology, Cardiac Electrophysiology and Pacing, Soroka University Hospital, Israel
⁵Department of Cardiology, Hadassah Medical Organization, Israel
⁶Cardiology Department, Meir Medical Center, Israel
⁷Department of Cardiology, Electrophysiology and Pacing Unit, Assuta Ashdod University Medical Center, Israel
⁸Eyal Ofer Heart Hospital, Cardiac Electrophysiology and Pacing, Rambam Health Care Campus, Israel

Background: Pulmonary vein isolation (PVI) for atrial fibrillation (AF) is commonly performed, yet the influence of hospital size and procedural volume on outcomes in Israel remains unclear. Although some evidence suggests that higher procedural volume may correlate with better outcomes, no optimal threshold has been established, and guidelines emphasize center-specific performance metrics. This study compared the safety and efficacy of catheter ablation (CA) at large (LMCs) versus small (SMCs) medical centers in Israel.

Methods: This prospective, multicenter observational study drew on the Israeli Catheter Ablation Registry (ICAR), covering all AF ablation procedures at 14 centers from January 2019 to December 2021. Centers were categorized by hospital bed capacity and annual procedural volume. Patient demographics, comorbidities, echocardiographic findings, procedural details, and follow-up outcomes were documented. The primary endpoint was AF recurrence beyond an eight-week blanking period, confirmed electrocardiographically. Safety endpoints included acute and chronic complications. Inverse probability of treatment weighting (IPTW) addressed baseline imbalances between LMCs and SMCs.

Results: Among 1,002 patients (mean age 64.1±11.3 years; 37.5% female; 65.3% paroxysmal AF), 58.7% were treated at LMCs and 41.3% at SMCs. Most ablations (84.6%) were performed using cryoballoon ablation (CBA). Patients at SMCs had a higher comorbidity burden, including diabetes and non-paroxysmal AF. Before IPTW, SMCs showed lower AF recurrence rates at one and two years. After adjustment, recurrence did not differ significantly (one-year: 11.4% vs. 15.6%, p=0.213; two-year: 14.4% vs. 21.3%, p=0.07). Overall complication rates were low, although SMCs had a slightly higher incidence of peripheral vascular events.

Conclusion: PVI—primarily using CBA—was comparably safe and effective at smaller centers, suggesting that with adequate training and resources, SMCs can achieve outcomes similar to larger institutions. Although complex cases may still be best managed at high-volume centers, our findings indicate that CBA may mitigate the impact of center size on procedural outcomes.