Undiagnosed OSA and AF recurrence after ablation (OSA-AF study) 53 1. Introduction There is an association between sleep-disordered breathing (SDB) and atrial fibrillation (AF). The putative mechanisms for AF vulnerability in SDB patients seem to be a combination of left atrial (LA) dilatation, altered autonomic nerve activity, neuro-humoral activation and electrical atrial remodelling (e.g., atrial conduction slowing, reduction of atrial effective refractory period) (1). Observational studies and meta-analyses have shown a negative impact of SDB on the efficacy of catheter ablation of AF, with a 25% increased risk of AF recurrence (2–6). This lower efficacy may be partly explained by an increased incidence of non-pulmonary vein triggers (7). Treatment of SDB with continuous positive airway pressure (CPAP) improves arrhythmia-free survival after catheter ablation in observational studies, with a 42% risk reduction of AF recurrence (8–10). The 2020 European Society of Cardiology (ESC) guidelines recommend that SDB treatment should be optimized to improve AF treatment results (11–12). The clinical challenge, however, is that many patients with SDB have limited symptoms such as daytime sleepiness or feelings of fatigue which results in underdiagnosis of SDB (13–15). At present, the role of opportunistic screening for SDB before catheter ablation of AF is unclear. The aim of the current study is to evaluate if undiagnosed, thus untreated, SDB was associated with AF recurrence within the first year after initial catheter ablation of AF. To prevent bias due to SDB treatment, we evaluated the presence or absence of SDB, as measured with a dedicated sleep apnea testing device, at least one year after the initial catheter ablation. In addition, we also tested the utility of commonly used SDB screening questionnaires such as STOP-BANG and the Epworth Sleepiness Scale (ESS) to predict SDB in this specific patient population. 2. Methods 2.1. Study population The Effect of undiagnosed Obstructive Sleep Apnea in patients undergoing Atrial Fibrillation catheter ablation (OSA-AF) study was a cross-sectional single-center cohort study. We included consecutive patients after a first catheter ablation of AF in the Erasmus MC, University Medical Center Rotterdam, the Netherlands from December 2018 to February 2020. Eligible patients were adults who had a first 4
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