https://doi.org/10.1007/s00392-025-02625-4
1Universitätsklinikum des Saarlandes Innere Medizin III - Kardiologie, Angiologie und internistische Intensivmedizin Homburg/Saar, Deutschland; 2University of Cape Town Cape Heart Institute, Faculty of Health Sciences Cape Town, Südafrika; 3Marienhospital Herne, Klinikum der Ruhr-Universität Bochum Med. Klinik II, Kardiologie u. Angiologie Herne, Deutschland
Catheter ablation is the cornerstone in the management of patients with atrial fibrillation (AF). Despite its effectiveness in achieving rhythm control, a significant proportion of patients requires a repeat ablation procedure for AF recurrence. In this systematic review and meta-analysis, we aimed to provide a comprehensive summary of current practices and overview of the procedural findings at redo ablations, as well as summarize the recurrence rates thereafter.
Methods:
We systematically searched PubMed/MEDLINE, Web of Science, and Scopus for articles from inception until end of December 2023 including studies on patients undergoing a first redo procedure for AF recurrence. The primary outcome was to report the pooled prevalence estimates of atrial fibrillation (AF) recurrence along with their 95% confidence intervals (CIs).
Results:
Our meta-analysis included 57 studies comprising 8,243 patients with a median age of 61.1 years ([95% CI 59.0-63.1], I2 = 0.00%). Over two-thirds of patients had their initial catheter ablation for paroxysmal AF, with radiofrequency ablation (RFA) being the more common technique compared to cryoballoon ablation (CBA) (61.4% vs. 36.2%). The majority of patients (81.9%, [95% CI 76.9-86.4], I2 = 96.38%) had at least one reconnected pulmonary vein (PV) at the redo procedure. Studies published after 2019 showed lower PV reconnection rates (78.9 [95% CI 72.5-84.6], I2 = 97.00%) compared to earlier publications (87.6%, [95% CI 79.2-94.2], I2 = 94.17%). The redo procedure was predominantly performed with RFA (95.4%, [95% CI 90.6-98.7], I² = 98.50%). The most frequently performed additional linear ablation was cavotricuspid isthmus (CTI) ablation, carried out in 26.0% of cases ([95% CI 17.9-35.0], I² = 98.20%). Other linear ablation strategies included mitral isthmus lines in 7.8% ([95% CI 3.4-13.6], I² = 97.97%), roof lines in 8.7% ([95% CI 4.0-14.9], I² = 98.05%), and posterior wall lines in 7.0% ([95% CI 2.7-13.0], I² = 98.19%) of cases. Overall, 32.0% ([95% CI 28.9-35.1], I² = 88.35%) of the population in this meta-analysis experienced AF recurrence after a median follow-up of 11.5 months ([95% CI 9.9-13.6], I² = 0.00%) following the redo procedure. A shorter interval between the initial and redo ablation (≤ 12 months) showed significantly lower recurrence rates compared to those with longer intervals. (25.5% ([95% CI 20.3-31.0], vs 33.9% ([95% 30.2-37.7], I² = 88.4%).
Conclusion:
Reconnected PVs are highly prevalent during redo ablation procedures, indicating that PVI continues to be the predominant ablation strategy in these cases. Patients initially treated with CBA showed lower PV reconnection rates compared to those with RFA. About one-third of patients experienced AF recurrence after redo ablation, with shorter intervals between the initial and redo procedures associated with reduced recurrence rates.