Atrial fibrillation catheter ablation, brain glymphatic function, and cognitive performance.

Summary

In AF patients, the DTI-ALPS index of glymphatic function was reduced vs controls, especially in nonparoxysmal AF, and correlated with worse performance on multiple cognitive tests. Mediation analyses suggested glymphatic dysfunction mediates AF-related cognitive decline, and the ALPS index improved after catheter ablation.

Key Findings

• AF patients had lower DTI-ALPS glymphatic index than healthy controls (P=.016), with nonparoxysmal AF lowest.
• Lower ALPS index correlated with worse executive function and processing speed (Trail Making, Digit Symbol, Digit Span, Stroop; all P<.05).
• Mediation analysis indicated glymphatic activity mediates the AF–cognition association; ALPS improved post-ablation (P=.015) in 50 patients.

Clinical Implications

Supports considering cognitive monitoring in AF and provides a mechanistic rationale for rhythm control (ablation) to mitigate neurocognitive decline, especially in persistent AF.

Limitations

• Non-randomized case-control and before–after design; potential confounding remains.
• Short-term post-ablation imaging; long-term cognitive outcomes were not assessed.

Future Directions

Randomized trials to test whether rhythm control improves long-term cognitive outcomes and to define which AF phenotypes benefit most mechanistically.