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Background - A very late recurrence (VLR) of atrial fibrillation (AF) is considered present when the first recurrence of AF occurs ≥ 12 months following ablation. Prior studies characterizing VLR have not used an implantable loop recorder (ILR) for ECG monitoring. Thus, it is unknown whether VLR truly occurs or whether these patients have simply had unrecognized AF. Our objective was to assess the incidence and predictors of VLR in patients who underwent cryoballoon (CB) pulmonary vein isolation (PVI) alone, had an ILR, and were confirmed AF-free for at least 1 year. Methods - We enrolled consecutive patients with paroxysmal or persistent AF who underwent CB PVI and had an ILR implanted < 3 months post-ablation. Patients free of AF 1-year post-ablation were followed prospectively for recurrent AF. All AF episodes were adjudicated. Results - We included 188 patients (66 ± 10 years; 116 [62%] male; 102 (54%) paroxysmal AF; CHA 2 DS 2 -VASc 2.6 ± 1.7). After 1-year post-PVI, 93 (49%) patients remained AF free. During subsequent follow-up, 30 (32%) patients had VLR of AF. The only independent risk factor for VLR was an elevated CHA 2 DS 2 -VASc score (HR 1.317 [95% CI: 1.033-1.6979], p=0.026). Patients with CHA2DS2-VASc score ≥ 4 represented a quarter of the population and were at highest risk. Conclusions - Our data using ILRs for continuous ECG monitoring post AF ablation show that VLR occurs in a third of patients after an apparently successful CB PVI procedure. Additional strategies are needed to ensure long-term freedom from AF recurrences in these high-risk patients.

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