Empirical superior vena cava isolation improves outcomes of radiofrequency re-ablation in pulmonary vein isolation non-responders: A 2-center retrospective study in China

Abstract

BackgroundPulmonary vein isolation (PVI) is the standard ablation strategy for treating atrial fibrillation (AF). However, the optimal strategy of a repeat procedure for PVI non-responders remains unclear.ObjectiveThis study aims to investigate the incidence of PVI non-responders in patients undergoing a repeat procedure, as well as the predictors for the recurrence of repeat ablation.MethodsA total of 276 consecutive patients who underwent repeat ablation from August 2016 to July 2019 in two centers were screened. A total of 64 (22%) patients with durable PVI were enrolled. Techniques such as low voltage zone modification, linear ablation, non-PV trigger ablation, and empirical superior vena cava (SVC) isolation were conducted.ResultsAfter the 20.0 ± 9.9 month follow-up, 42 (65.6%) patients were free from atrial arrhythmias. A significant difference was reported between the recurrent and non-recurrent groups in non-paroxysmal AF (50 vs. 23.8%, p = 0.038), diabetes mellitus (27.3 vs. 4.8%, p = 0.02), and empirical superior vena cava (SVC) isolation (28.6 vs. 60.5%, p = 0.019). Multivariate regression analysis demonstrated that empirical SVC isolation was an independent predictor of freedom from recurrence (95% CI: 1.64–32.8, p = 0.009). Kaplan-Meier curve demonstrates significant difference in recurrence between empirical and non-empirical SVC isolation groups (HR: 0.338; 95% CI: 0.131–0.873; p = 0.025).ConclusionAbout 22% of patients in repeat procedures were PVI non-responders. Non-paroxysmal AF and diabetes mellitus were associated with recurrence post-re-ablation. Empirical SVC isolation could potentially improve the outcome of repeat procedures in PVI non-responders.

Efficacy, Safety and Feasibility of Superior Vena Cava Isolation in Patients Undergoing Atrial Fibrillation Catheter Ablation: An Up-to-Date Review

“…Gu et al have examined data from patients that have had AF recurrence and no PV reconnection during redo ablation, and found that empiric SVCI was associated with increased arrhythmia free survival (79.3 vs. 50.0%; HR: 0.338; 95% CI: 0.131–0.873; p = 0.025). This was a small retrospective study and larger randomized trials are much anticipated [ 55 ].…”

“…Many patients with SVC foci are only discovered during redo ablation; hence, finding which clinical phenotype is benefited remains to be answered. ’’The increasing implementation of CBA and contact force RFA might lead to an era of reduced PV reconnection and the number of the so-called PVI non responders necessitating specialized treatment during redo ablation will increase [ 55 ]. Besides PVI non-responders, patients undergoing repeated CBA procedures [ 54 ] and patients with long SVC sleeves [ 26 , 41 ] or arrhythmogenic RSPV [ 22 , 34 ] could be optimal candidates for SVCI, especially via an empiric approach.…”

Atrial Fibrillation and Chronic Coronary Ischemia: A Challenging Vicious Circle

“…For patients with persistent forms of AF, it is more likely to have non-PV triggers, such as the left atrial posterior free wall [ 18 , 19 , 20 ], the left atrial appendage [ 21 ], the superior vena cava (young patients with AF had a higher incidence of only non-PV foci, mostly located here) [ 22 , 23 , 24 , 25 ], the coronary sinus [ 26 , 27 ], and the ligament of Marshall [ 28 , 29 ]. For non-PV foci patients, the isolation of them was a significant factor affecting the achievement of better clinical outcomes following AF ablation [ 30 ].…”