However, evidence on the efficacy and safety of catheter ablation for rhythm control in elderly patients remain limited. A retrospective, population-based cohort study by Kim et al.4) showed that the benefit of rhythm control over rate control was limited in patients aged ≥75 years. Recent study reported that 1-year arrhythmia-free survival rate in octogenarians who underwent RFA, CBA or pulsed-field ablation (PFA) was 72.6%, which is comparable to previously reported recurrence rates in younger populations.6) These studies suggest that catheter ablation showed reasonable effectiveness, which may be considered an option of the rhythm control strategy, even in elderly patients with AF.

In this issue of Korean Circulation Journal, Kang et al.5) provides an evidence supporting the effectiveness and safety of CBA in Korean elderly patients (≥75 years). Unlike previous studies which included limited number of older patients, this study enrolled 249 patients aged ≥75 years, enabling a more robust comparison with younger counterparts (<75 years). Kang et al.6) showed that CBA is both safe and effective in elderly patients, with outcomes comparable to those observed in younger individuals. Even after adjusting for potential confounders, there was no significant difference in AT recurrence between the elderly and younger groups (HR, 0.91; 95% CI, 0.62–1.34; p=0.63). Similarly, procedure-related complications did not differ significantly between the groups (6.4% in elderly vs. 4.3% in younger patients, p=0.18), further supporting the safety profile of CBA in this population. However, as a limitation of retrospective registry studies, detailed procedural characteristics were not obtained nor analyzed. In addition, clinical outcomes such as cardiovascular events were not collected during the follow-up period, limiting the assessment of long-term prognostic impact beyond arrhythmia recurrence. These limitations highlight the need for further prospective studies to evaluate long-term outcomes following CBA in elderly patients. Future prospective studies in the elderly patients need to incorporate data collection on procedural variables, including ablation technique, lesion set and operator experience, in order to assess their impact on outcomes. Moreover, holistic approach with systematic follow-up for predefined endpoints, such as stroke, heart failure hospitalization, and overall survival, will provide a more comprehensive understanding of the long-term risks and benefits of CBA in this population. In addition, integrating biomarkers, imaging modalities and quality-of-life assessments can further refine risk stratification and inform patient selection. However, this study may mitigate concerns regarding the safety of CBA in elderly Asian patients, a population characterized by lower body weight and a higher prevalence of renal impairment.

In the context of the emerging PFA era, this study is also expected to be relevant for the adoption of PFA in elderly AF patients. A recent study by Nakasone et al.,7) which examined one-year AT recurrence rates following catheter ablation in elderly AF patients, reported no significant differences in recurrence rates between PFA, CBA or RFA groups, while the overall complication rates remained comparable across the groups. Moreover, PFA showed shorter procedure time and potentially lower complication risk, which seem to be distinct advantages in elderly patients. There are growing evidences that supports PFA as an effective option for elderly patients, thereby advancing the paradigm of catheter-based rhythm control strategies beyond conventional approaches.

These data provide clinical insight to determine whether to consider catheter-based rhythm control strategies in older patients. However, it also raise a question about which patients benefit from catheter ablation.