1Herzzentrum der Universität zu Köln Elektrophysiologie Köln, Deutschland
Background
Pulmonary vein isolation (PVI) is the cornerstone in treatment of atrial fibrillation (AF). Despite initially successful PVI patients experience recurrence of AF mostly due to reconnection of pulmonary veins (PVs). However, a certain number of patients presents with recurrent AF despite durable PVI. The optimal ablation strategy for these patients has yet to be discerned.
Aim
The aim of this study was to compare outcomes for different ablation strategies for recurrent AF despite persistent PVI.
Methods
All redo procedures for recurrence of AF from 01/2016 – 6/2022 at our center were analyzed. Only patients with proven durable PVI (entrance/exit block and high density (HD) mapping) were included. Patients were excluded, if re-PVI or right atrial ablation was necessary. In all procedures (HD) 3-D mapping and radiofrequency ablation were performed. Ablation strategy was at operators’ discretion. A 12-month follow up (FU) was obtained.
Results
A total of 405 left-atrial procedures for the recurrence of AF were analyzed. In 85 (21.0%) procedures all PVs were still isolated. Of these 30 patients (35.3 %) were female and 70 patients (82.4 %) suffered from persistent AF. In 49 patients (57.6 %) LA scar was detectable (85.7 % persAF). The ablation strategies consisted of: roof line (n=9; 10.6 %), left atrial anterior line (n=8, 9.4 %), roof line and left atrial anterior line (n=8, 9.4%), roof line and left atrial inferior line (n=18, 21.2 %), box lesion (n=6, 7.1 %), other left atrial ablation lines (n=20, 23.5 %) and substrate modification (CFAE and substrate encirclement) (n=16, 18.8 %). In patients with PAF (n=15), 3 patients received a roof line (20.0 %), 3 patients received the latter and left atrial inferior line (20.0 %), 5 patients received other left atrial ablation lines (33.3 %) and 4 patients received substrate modification (CFAE and substrate encirclement) (26.7 %). After a mean follow up of 401 +/- 125 days 55.3 % (n=47) of patients were free from any atrial arrhythmia (roof line 77.8 +/- 15 %, left atrial anterior line 87.5 +/- 13 %, roof line and left atrial anterior line 37.5 +/- 18 %, roof line and left atrial inferior line 50 +/- 12 %, box lesion 83.3 +/- 17 %, other left atrial ablation lines 45.0 +/- 11 %, substrate modification (CFAE and substrate encirclement) 43.8 +/- 13 %, p=0.122), 35.3 % (n=30) showed recurrence of AF (p=0.287) and 9.4 % (n=8) showed atrial tachycardia (AT) (p=0.693). None of the ablation strategies led to a significantly superior outcome.
Conclusion
In patients suffering from recurrence of AF despite durable pulmonary vein isolation different substrate modification strategies did not show any superiority for one or the other. Despite the necessity of additional ablation beyond PVI the optimal ablation strategy needs to be yet determined to improve outcome for redo procedures.