Recurrent Atrial Fibrillation After Initial Long-Term Ablation Success

Abstract

BACKGROUND:Atrial fibrillation recurrence after initial long-term success of catheter ablation has been described, yet not well studied. We assessed the electrophysiological findings and outcomes of repeat ablation procedures in this setting. METHODS AND RESULTS:Between 2000 and 2015, 10 378 patients underwent atrial fibrillation ablation and were enrolled in a prospectively maintained data registry. From this registry, we included all 137 consecutive patients who had initial long-term success, defined as freedom from recurrent arrhythmia for >36 months off antiarrhythmics, then underwent repeat ablation for recurrent atrial fibrillation. The median arrhythmia-free period that defined long-term success was 52 months (41-68 months). In redo ablations, reconnection along at least one of the pulmonary veins (PVs) was found in 111 (81%) patients. Reconnection along a left superior, left inferior, right superior, and right inferior PV was found in 64%, 62%, 50%, and 54% of patients, respectively, and were reisolated. Additional non-PV ablations were performed in 127 (92.7%) patients: posterior wall (46%), septal to right PVs (49%), superior vena cava (35%), roof lines (52%), and cavotricuspid isthmus (33%). After a median follow-up of 17 months (5-36.9 months), 103 patients (75%) were arrhythmia free (79 off antiarrhythmics, 24 on antiarrhythmics). CONCLUSIONS:PV reconnection is the most common electrophysiological finding in patients with atrial fibrillation recurrence after long-term success, but with lower rates than what had been reported for early recurrences. In our experience, repeat ablations in this setting involve complex ablation approaches to reisolate the PVs and modify the atrial substrate and are associated with good success rates.

Efficacy of LGE‐MRI‐guided fibrosis ablation versus conventional catheter ablation of atrial fibrillation: The DECAAF II trial: Study design

“…Follow‐up LGE‐MRIs collected in patients after AF ablation provides valuable information to assess chronic ablation lesion formation and efficient PVI encirclement. Indeed, a major reason for recurrence after ablation in AF patient is the formation of PV reconnections 42 . In addition, the clinical relevance of the operator residual and residual fibrosis can be investigated by comparing collected electro‐anatomical mapping ablation points to baseline fibrosis images and 3‐month scar images, respectively, allowing us to explore novel procedural endpoints.…”

Efficacy and safety of the second‐generation cryoballoon ablation for the treatment of persistent atrial fibrillation in elderly patients

“…In our cohort, even though a repeat procedure was less frequently performed in older patients, the proportion of patients presenting with a PV reconnection was similar in both groups. Although PV reconnections are also an important factor affecting long‐term ablation outcomes 17 ; however, assuming equal procedural characteristics, it is safe to assume an equal incidence of PV reconnection between groups, in consequence, another variable beyond PV triggers should be the cause of the worst outcomes in the elder group.…”

Electrocardiogram characteristics of P wave associated with successful pulmonary vein isolation in patients with paroxysmal atrial fibrillation: Significance of changes in P‐wave duration and notched P wave

“…Recurrence after ablation is considered the reconnection of electrical conduction between the PV and left atrium (LA) in patients with paroxysmal AF. During a repeat procedure for recurrence cases, there may be multiple PV reconnections, despite the development of advanced ablation techniques and devices Shah et al, 2018;Zucchelli et al, 2018). Even reconnection of one PV with a critical arrhythmogenic substrate can be responsible for the recurrence of AF following ablation.…”