Abstract

Importance  Atrial fibrillation (AF) is associated with cognitive impairment, but the cognitive effects of catheter ablation (CA) using contemporary techniques remain uncertain.

Objective  To evaluate changes in global and domain-specific cognitive function after CA for AF.

Design, Setting, and Participants  This prospective cohort study included consecutive patients undergoing CA for AF and a nonablation AF control group at a tertiary university hospital in Greece between January 2022 and June 2024. Cognitive assessments were performed at baseline and at 6-month follow-up.

Exposures  CA using cryoballoon or pulsed field ablation (PFA).

Main Outcomes and Measures  Changes from baseline to 6 months in Montreal Cognitive Assessment (MoCA) scores and the novel REMEDES for Alzheimer (R4Alz) total and subdomain scores. Brain magnetic resonance imaging was performed before and within 48 hours after ablation to detect new cerebral infarcts.

Results  Among 75 patients (40 [53.3%] female) undergoing ablation (mean [SD] age, 61.9 [10.4] years; 54 cryoballoon, 21 PFA) and 40 in a nonablation control group (26 [65.0%] female; mean [SD] age,61.4 [9.2] years), baseline cognitive scores were similar between groups. No new cerebral infarcts were detected after ablation. At 6 months, MoCA scores in the ablation group did not change significantly (mean change, 0.27; 95% CI, −0.08 to 0.62), whereas R4Alz total scores increased (mean change, 2.81; 95% CI, 1.55 to 4.07), mainly associated with gains in short-term working memory and perceptual inhibition. No significant changes were observed in the control group. Compared with the control group, the ablation cohort demonstrated significantly greater improvements in both MoCA (mean difference in change, 0.74; 95% CI, 0.17 to 1.31; P = .01) and R4Alz total score (mean difference in change score, 3.18; 95% CI, 0.87 to 5.49; P = .007). In adjusted analyses accounting for baseline cognitive score and clinical covariates, ablation was independently associated with higher follow-up MoCA (β = 0.88; 95% CI, 0.31 to 1.44) and R4Alz scores (β = 3.80; 95% CI, 1.70 to 5.90).

Conclusions and Relevance  In this prospective observational cohort study of 75 patients undergoing CA for AF, ablation was not associated with cognitive decline and was instead associated with modest short-term improvements in selected cognitive domains. Domain-specific assessment detected changes not captured by global cognitive screening, suggesting that modern ablation techniques may be associated with early subtle cognitive gains.

Introduction

Atrial fibrillation (AF) is associated with a higher risk of cognitive impairment and dementia, even in the absence of overt stroke.1 Several mechanisms have been proposed, including silent cerebral infarction, cerebral hypoperfusion due to irregular rhythm and impaired cardiac output, systemic inflammation, and microembolic events.2

Catheter ablation (CA) is now an established therapy for AF, improving rhythm control and quality of life.3 However, its impact on cognitive function remains uncertain. Some studies have shown that restoration of sinus rhythm and improved hemodynamics may benefit cognition, while others have reported transient cognitive decline after ablation, possibly linked to silent cerebral emboli.4,5

The Montreal Cognitive Assessment (MoCA) is the most widely used screening tool for mild cognitive impairment, but it may not adequately capture domain-specific cognitive impairments.6 The REMEDES for Alzheimer (R4Alz) battery is a novel computerized tool originally developed for the early detection of Alzheimer disease and is designed to evaluate working memory, attention control, and executive functions using REMEDES pads, which present visual and auditory stimuli requiring rapid motor-cognitive responses with the goal to be less affected by cultural and educational factors.7 It may therefore provide a more sensitive measure of cognitive performance in patients with AF undergoing ablation. This study evaluated cognitive function before and 6 months after CA using both MoCA and the R4Alz battery, hypothesizing that R4Alz would detect minor changes in cognitive function compared with MoCA.