Reliable prediction of very late recurrence of atrial fibrillation (VLRAF) occuring >12 months after catheter ablation (CA) in apparently "cured" patients could optimize long-term follow-up and modify decision-making regarding the discontinuation of oral anticoagulant therapy. In a single-centre cohort of consecutive patients post radiofrequency AFCA, we retrospectively derived a novel score for VLRAF prediction. Of 133 consecutive post AFCA patients (mean age 56.9 ± 11.8 years, 63.9% male, 69.2% with paroxysmal AF) who were arrhythmia-free at 12 months (excluding 3-month "blanking period"), Catheter-ablation (CA) is superior to antiarrhythmic drugs (AADs) in patients with symptomatic atrial fibrillation (AF), but AF may re-occur despite multiple re-do procedures and recent technical improvements 1,2 . Most arrhythmia recurrences are identified within the first year after the procedure, while further long-term follow-up strategy for initially "successfully" treated patients is less well defined and inconsistently reported 1-9 .Several studies described a progressive increase in the arrhythmia recurrence rates over time in patients with initial post-ablation suppression of AF 4-6 . It is reported that 10-40% of patients who were arrhythmia free within the first post-procedural year experienced very late recurrence of AF (VLRAF) over long-term follow-up 2-9 . Several scoring systems (i.e., the APPLE, ALARMc and BASE-AF2 score) were recently proposed to predict the short-term risk of AF recurrence after the procedure 10-12 . However, none of these scores have addressed VLRAF occurring in patients who were free of AF at 1 year post procedure. Importantly, reliable identification of increased risk of VLRAF could strongly influence decision-making regarding the long-term use of oral anticoagulation and/or AAD therapy as well as the long-term monitoring strategy after the procedure 1,2 . Due to altered risk/benefit ratio, multiple AF ablation procedures may not be justified in patients at high risk of recurrent AF, and reliable prediction of VLRAF could optimize the patient selection for re-do CA 1,2,9,11 .

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IntroductionCardiac tamponade (CT) is a life-threatening complication of radiofrequency ablation (RFA). The course and outcome of CT in low-to-medium volume electrophysiology centers are underreported.MethodsWe analyzed the incidence, management and outcomes of CT in 1500 consecutive RFAs performed in our center during 2011–2016.ResultsOf 1500 RFAs performed in 1352 patients (age 55 years, interquartile range: 41–63), 569 were left-sided procedures (n = 406 with transseptal access). Conventional RFA or irrigated RFA was performed in 40.9% and 59.1% of procedures, respectively. Ablation was performed mostly for atrioventricular nodal reentrant tachycardia (25.4%), atrial fibrillation (AF; 18.5%), atrial flutter (18.4%), accessory pathway (16.5%) or idiopathic ventricular arrhythmia (VA; 12.3%), and rarely for structural VA (2.1%). CT occurred in 12 procedures (0.8%): 10 AF ablations, 1 idiopathic VA and 1 typical atrial flutter ablation. Factors significantly associated with CT were older age, pre-procedural oral anticoagulation, left-sided procedures, transseptal access, AF ablation, irrigated RFA and longer fluoroscopy time (on univariate analysis), and AF ablation (on multivariable analysis). The perforation site was located in the left atrium (n = 7), right atrium (n = 3), or in the left ventricle or coronary sinus (n = 1 each). Upon pericardiocentesis, two patients underwent urgent cardiac surgery because of continued bleeding. There was no fatal outcome. During the follow-up of 19 ± 14 months, eight patients were arrhythmia free.ConclusionIncidence of RFA-related CT in our medium-volume center was low and significantly associated with AF ablation. The outcome of CT was mostly favorable after pericardiocentesis, but readily accessible cardiothoracic surgery back-up should be mandatory in RFA centers.

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