Early recurrence after pulmonary vein isolation is associated with inferior long‐term outcomes: Insights from a retrospective cohort study

Abstract

Aims: The aim of this retrospective cohort study was to assess the influence of early recurrence (ER) after pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) on long-term outcomes and to identify clinical variables associated with ER. Methods: We retrospectively collected clinical and procedural data from 1285 patients with paroxysmal AF who underwent PVI from 2011 to 2016. Kaplan-Meier, receiver operating characteristic (ROC) curve, logistic and Cox regression analyses were performed to analyze the influence of ER on long-term outcomes. Results: ER was observed in 13% of patients. Kaplan-Meier analyses showed significantly different outcomes in 1285 patients with and without ER (49% vs 74%, log rank P < .01) and in 286 patients in the subgroup that underwent reablation (44% vs 79%, log rank P < .01). The hazard ratio (HR) of ER was 1.7 within 48 hours (5% of patients), 2.7 within 1 month (5%), 3.0 within 2 months (2%), and 6.4 within 3 months (1%) for late recurrence (LR), P < .01. ROC analysis (area under the curve [AUC] = 0.79) resulted in 70.3% sensitivity and 74.2% specificity for a 14-day blanking period, and 53.1% sensitivity and 85.5% specificity for a 30-day blanking period. Female patients (odds ratio [OR] 1.69, P < .01) and those with diabetes (OR 1.95, P = .01) were at higher risk for ER. Conclusions: ER is observed in a substantial number of patients with paroxysmal AF after PVI and has a continuous direct effect on LR according to the timing of ER. Randomized trials are required to assess the safety and effects of reablations in a shortened blanking period on long-term outcomes.

Early arrhythmia recurrence after catheter ablation for persistent atrial fibrillation: is it predictive for late recurrence?

“…While ERAT in paroxysmal AF may be driven by transient mechanisms within the first weeks, ERAT in persistent AF could predominantly be caused by atrial substrate (involving atrial enlargement, scarring and slow conduction zones) which continues to be a driver of AF despite first ablation. This hypothesis is supported by the time-dependency between ERAT and LR in paroxysmal AF [ 2 , 8 , 10 ] as opposed to the rather dichotomous relationship we found in persistent AF patients. The association of ERAT with inferior multi-procedural outcomes is also suggestive for a non-transient cause of early recurrences.…”

“…We also found a different correlation between ERAT timing and LR than previously described for paroxysmal AF, where the risk of relapse is known to gradually increase with later ERAT occurrence [2,8,10]. In our cohort, the risk of LR was rather equally high regardless of ERAT Table 3 Late recurrence according to first ERAT occurrence n = 182.…”

“…On multivariate analysis, ERAT was the only independent positive predictor of LR (OR 16.8, P < 0.001). This adds to the growing body of evidence that ERAT is highly predictive of LR in paroxysmal AF [ 2 , 8 ]. Rather surprisingly, the absence of ERAT following index ablation was also associated with superior multi-procedural outcomes in this study; patients without ERAT were to a significantly higher rate arrhythmia-free off AADs after less ablation procedures.…”

“…A recent meta-analysis investigating the predictive value of ERAT after RFCA included data which originates from ~ 90% paroxysmal AF patients, while the persistent AF population remains clearly underrepresented [ 9 ]. In the paroxysmal AF cohort, there is increasing evidence that ERAT after PVI predicts LR [ 2 , 8 , 16 ].…”

“…However, there is increasing evidence that ERAT following CA for paroxysmal AF is strongly associated with late recurrence (LR) beyond the blanking period [ 1 , 2 , 8 ]. In contrast, the prognostic significance of ERAT in patients with persistent and long-standing persistent AF is poorly defined, since the majority of data (~ 90%) originates from paroxysmal AF patient cohorts [ 9 ].…”