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Outcomes of a comprehensive strategy during repeat atrial fibrillation ablation

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A Correction to this article was published on 14 June 2022

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Abstract

Background/purpose

Atrial fibrillation (AF) recurs post-ablation in 30–40% of patients. The approach to a repeat ablation, beyond isolation of reconnected pulmonary veins (PVs), is not well established. We sought to prospectively assess outcomes and predictors of recurrence among consecutive patients who underwent repeat AF ablation with a standardized approach.

Methods

This was a single-center prospective study of consecutive patients who underwent repeat AF ablation. Our protocol consisted of six steps: PV re-isolation, ablation of left atrial low-voltage areas (LVAs), ablation of isoproterenol-induced non-PV triggers, electrophysiology study (EPS) and ablation of induced AVNRT/AVRT, ablation of induced clinical atrial flutters, and lastly empiric ablation as per operator discretion if no other ablation was performed.

Results

Among 725 AF ablations performed during the study period, 74 were repeat ablations. Of those undergoing repeat ablation, 53 (72%) had PV reconnection, 30 (41%) had LVAs, seven (10%) had non-PV triggers, five (7%) had AVNRT, and 15 (20%) had typical atrial flutter. Following repeat ablation, arrhythmia-free survival was 65% at 1 year. The absence of PV reconnection was the only factor independently associated with recurrence after repeat ablation (recurrence rate 71%, adjusted OR 7.91, 95% CI 2.31–27.16, p = 0.001).

Conclusions

A comprehensive approach to repeat AF ablation including PV re-isolation, LVA ablation, non-PV trigger ablation, EPS, and flutter ablation was associated with a 65% 1-year arrhythmia-free survival. The absence of PV reconnection was the only independent predictor of arrhythmia recurrence. Further research is needed to identify therapies beyond PV isolation for patients undergoing repeat ablation.

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Abbreviations

AF:

Atrial fibrillation

PV:

Pulmonary vein

SVC:

Superior vena cava

LVA:

Low voltage areas

LA:

Left atrium

EPS:

Electrophysiology study

CTI:

Cavo-tricuspid isthmus

APDs:

Atrial premature depolarizations

AVNRT:

AV-nodal re-entrant tachycardia

AVRT:

Atrioventricular re-entrant tachycardia

ECG:

Electrocardiogram

PVI:

Pulmonary vein isolation

References

  1. Wokhlu A, Monahan KH, Hodge DO, Asirvatham SJ, Friedman PA, Munger TM, … Packer DL. Long-term quality of life after ablation of atrial fibrillation the impact of recurrence, symptom relief, and placebo effect. J Am Coll Cardiol. 2010;55(21):2308–2316. https://doi.org/10.1016/j.jacc.2010.01.040

  2. Wokhlu A, Hodge DO, Monahan KH, Asirvatham SJ, Friedman PA, Munger TM, … Packer DL. Long-term outcome of atrial fibrillation ablation: impact and predictors of very late recurrence. J Cardiovasc Electrophysiol. 2010;21(10):1071–1078. https://doi.org/10.1111/j.1540-8167.2010.01786.x

  3. Hussein AA, Saliba WI, Martin DO, Bhargava M, Sherman M, Magnelli-Reyes C, … Wazni O. Natural history and long-term outcomes of ablated atrial fibrillation. Circ Arrhythm Electrophysiol. 2011;4(3):271–278. https://doi.org/10.1161/CIRCEP.111.962100

  4. Bhargava M, Di Biase L, Mohanty P, Prasad S, Martin DO, Williams-Andrews M, … Natale A. Impact of type of atrial fibrillation and repeat catheter ablation on long-term freedom from atrial fibrillation: results from a multicenter study. Heart Rhythm. 2009;6(10):1403–1412. https://doi.org/10.1016/j.hrthm.2009.06.014

  5. Cappato R, Calkins H, Chen S-A, Davies W, Iesaka Y, Kalman J, … Biganzoli E. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3(1):32–38. https://doi.org/10.1161/CIRCEP.109.859116

  6. Lin D, Santangeli P, Zado ES, Bala R, Hutchinson MD, Riley MP, … Marchlinski FE. Electrophysiologic findings and long-term outcomes in patients undergoing third or more catheter ablation procedures for atrial fibrillation. J Cardiovasc Electrophysiol. 2015;26(4):371–377. https://doi.org/10.1111/jce.12603

  7. Cappato R, Negroni S, Pecora D, Bentivegna S, Lupo PP, Carolei A, … De Ambroggi L. Prospective assessment of late conduction recurrence across radiofrequency lesions producing electrical disconnection at the pulmonary vein ostium in patients with atrial fibrillation. Circulation. 2003;108(13):1599–1604. https://doi.org/10.1161/01.CIR.0000091081.19465.F1

  8. Callans DJ, Gerstenfeld EP, Dixit S, Zado E, Vanderhoff M, Ren J-F, Marchlinski FE. Efficacy of repeat pulmonary vein isolation procedures in patients with recurrent atrial fibrillation. J Cardiovasc Electrophysiol. 2004;15(9):1050–5. https://doi.org/10.1046/j.1540-8167.2004.04052.x.

    Article  PubMed  Google Scholar 

  9. Takigawa M, Takahashi A, Kuwahara T, Okubo K, Takahashi Y, Nakashima E, … Isobe M. Impact of non-pulmonary vein foci on the outcome of the second session of catheter ablation for paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol. 2015;26(7):739–746. https://doi.org/10.1111/jce.12681

  10. Bisignani A, Overeinder I, Kazawa S, Iacopino S, Cecchini F, Miraglia V, … Chierchia GB. Posterior box isolation as an adjunctive ablation strategy with the second-generation cryoballoon for paroxysmal atrial fibrillation: a comparison with standard cryoballoon pulmonary vein isolation. J Interv Card Electrophysiol. 2021;61(2):313–319. https://doi.org/10.1007/s10840-020-00812-z

  11. Winkle RA, Mead RH, Engel G, Patrawala RA. Long-term results of atrial fibrillation ablation: the importance of all initial ablation failures undergoing a repeat ablation. Am Heart J. 2011;162(1):193–200. https://doi.org/10.1016/j.ahj.2011.04.013.

    Article  PubMed  Google Scholar 

  12. Chang T-Y, Lo L-W, Te ALD, Lin Y-J, Chang S-L, Hu Y-F, … Chen S-A. The importance of extrapulmonary vein triggers and atypical atrial flutter in atrial fibrillation recurrence after cryoablation: Insights from repeat ablation procedures. J Cardiovasc Electrophysiol. 2019;30(1):16–24. https://doi.org/10.1111/jce.13741

  13. Tang R-B, Yan X-L, Dong J-Z, Kalifa J, Long D-Y, Yu R-H, … Ma C-S. Predictors of recurrence after a repeat ablation procedure for paroxysmal atrial fibrillation: role of left atrial enlargement. Europace. 2014;16(11):1569–1574. https://doi.org/10.1093/europace/euu013

  14. Shah S, Barakat AF, Saliba WI, Abdur Rehman K, Tarakji KG, Rickard J, … Hussein AA. Recurrent atrial fibrillation after initial long-term ablation success: electrophysiological findings and outcomes of repeat ablation procedures. Circ Arrhythm Electrophysiol. 2018;11(4):e005785. https://doi.org/10.1161/CIRCEP.117.005785

  15. Liang JJ, Elafros MA, Muser D, Pathak RK, Santangeli P, Supple GE, … Dixit S. Comparison of left atrial bipolar voltage and scar using multielectrode fast automated mapping versus point-by-point contact electroanatomic mapping in patients with atrial fibrillation undergoing repeat ablation. J Cardiovasc Electrophysiol. 2017;28(3):280–288. https://doi.org/10.1111/jce.13151

  16. Nery PB, Al Dawood W, Nair GM, Redpath CJ, Sadek MM, Chen L, … Birnie DH. Characterization of low-voltage areas in patients with atrial fibrillation: insights from high-density intracardiac mapping. Can J Cardiol. 2018;34(8):1033–1040. https://doi.org/10.1016/j.cjca.2018.04.008

  17. Dixit S, Lin D, Frankel DS, Marchlinski FE. Catheter ablation for persistent atrial fibrillation: antral pulmonary vein isolation and elimination of nonpulmonary vein triggers are sufficient. Circ Arrhythm Electrophysiol. 2012;5(6):1216–23; discussion 1223. https://doi.org/10.1161/CIRCEP.111.970343.

    Article  PubMed  Google Scholar 

  18. Dixit S, Marchlinski FE, Lin D, Callans DJ, Bala R, Riley MP, … Gerstenfeld EP. Randomized ablation strategies for the treatment of persistent atrial fibrillation: RASTA study. Circ Arrhythm Electrophysiol. 2012;5(2):287–294. https://doi.org/10.1161/CIRCEP.111.966226

  19. Valles E, Fan R, Roux JF, Liu CF, Harding JD, Dhruvakumar S, … Marchlinski FE. Localization of atrial fibrillation triggers in patients undergoing pulmonary vein isolation: importance of the carina region. J Am Coll Cardiol. 2008;52(17):1413–1420. https://doi.org/10.1016/j.jacc.2008.07.025

  20. Kim T-H, Park J, Uhm J-S, Joung B, Lee M-H, Pak H-N. Pulmonary vein reconnection predicts good clinical outcome after second catheter ablation for atrial fibrillation. Europace. 2017;19(6):961–7. https://doi.org/10.1093/europace/euw128.

    Article  PubMed  Google Scholar 

  21. De Pooter J, Strisciuglio T, El Haddad M, Wolf M, Phlips T, Vandekerckhove Y, … Duytschaever M. Pulmonary vein reconnection no longer occurs in the majority of patients after a single pulmonary vein isolation procedure. JACC. Clin Electrophysiol. 2019;5(3):295–305. https://doi.org/10.1016/j.jacep.2018.11.020

  22. Kautzner J, Neuzil P, Lambert H, Peichl P, Petru J, Cihak R, … Kuck K-H. EFFICAS II: optimization of catheter contact force improves outcome of pulmonary vein isolation for paroxysmal atrial fibrillation. Europace. 2015;17(8):1229–1235. https://doi.org/10.1093/europace/euv057

  23. El Haddad M, Taghji P, Phlips T, Wolf M, Demolder A, Choudhury R, … Duytschaever M. Determinants of acute and late pulmonary vein reconnection in contact force-guided pulmonary vein isolation: identifying the weakest link in the ablation chain. Circ Arrhythm Electrophysiol. 2017;10(4):e004867. https://doi.org/10.1161/CIRCEP.116.004867

  24. Sadek MM, Maeda S, Chik W, Santangeli P, Zado ES, Schaller RD, … Marchlinski FE. Recurrent atrial arrhythmias in the setting of chronic pulmonary vein isolation. Heart Rhythm. 2016;13(11):2174–2180. https://doi.org/10.1016/j.hrthm.2016.08.026

  25. Huo Y, Kronborg MB, Richter U, Guo J, Ulbrich S, Zedda AM, … Piorkowski C. Electrophysiological findings during atrial fibrillation reablation: extending from pulmonary vein reconnection to sequential bipolar voltage map information. J Cardiovasc Electrophysiol. 2020;31(4):885–894. https://doi.org/10.1111/jce.14387

  26. Parkash R, Wells GA, Sapp JL, Healey JS, Tardif J-C, Greiss I, … Tang ASL. Effect of aggressive blood pressure control on the recurrence of atrial fibrillation after catheter ablation: a randomized, open-label clinical trial (SMAC-AF [substrate modification with aggressive blood pressure control]). Circulation. 2017;135(19):1788–1798. https://doi.org/10.1161/CIRCULATIONAHA.116.026230

  27. Steinberg JS, Shabanov V, Ponomarev D, Losik D, Ivanickiy E, Kropotkin E, … Romanov AB. Effect of renal denervation and catheter ablation vs catheter ablation alone on atrial fibrillation recurrence among patients with paroxysmal atrial fibrillation and hypertension: the ERADICATE-AF randomized clinical trial. JAMA. 2020;323(3):248–255. https://doi.org/10.1001/jama.2019.21187

  28. Linz D, McEvoy RD, Cowie MR, Somers VK, Nattel S, Lévy P, … Sanders P. Associations of obstructive sleep apnea with atrial fibrillation and continuous positive airway pressure treatment: a review. JAMA Cardiol. 2018;3(6):532–540. https://doi.org/10.1001/jamacardio.2018.0095

  29. Kanagala R, Murali NS, Friedman PA, Ammash NM, Gersh BJ, Ballman KV, … Somers VK. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107(20): 2589–2594. https://doi.org/10.1161/01.CIR.0000068337.25994.21

  30. Verma A, Wazni OM, Marrouche NF, Martin DO, Kilicaslan F, Minor S, … Natale A. Pre-existent left atrial scarring in patients undergoing pulmonary vein antrum isolation: an independent predictor of procedural failure. J Am Coll Cardiol. 2005;45(2):285–292. https://doi.org/10.1016/j.jacc.2004.10.035

  31. Masuda M, Fujita M, Iida O, Okamoto S, Ishihara T, Nanto K, … Mano T. Left atrial low-voltage areas predict atrial fibrillation recurrence after catheter ablation in patients with paroxysmal atrial fibrillation. Int J Cardiol. 2018;257: 97–101. https://doi.org/10.1016/j.ijcard.2017.12.089

  32. Rolf S, Kircher S, Arya A, Eitel C, Sommer P, Richter S, … Piorkowski C. Tailored atrial substrate modification based on low-voltage areas in catheter ablation of atrial fibrillation. Circ Arrhythm Electrophysiol. 2014; 7(5): 825–833. https://doi.org/10.1161/CIRCEP.113.001251

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Authors and Affiliations

  1. Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, H-1285A, Ottawa, Ontario, K1Y 4W7, Canada

    Willy Weng, David H. Birnie, F. Daniel Ramirez, Cassidy Van Stiphout, Mehrdad Golian, Pablo B. Nery, Simon P. Hansom, Calum J. Redpath, Andres Klein, Girish M. Nair, Wael Alqarawi, Martin S. Green, Darryl R. Davis & Mouhannad M. Sadek

  2. Department of Cardiac Sciences, College of Medicine, King Saud University, Riyadh, Saudi Arabia

    Wael Alqarawi

  3. The Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA

    Pasquale Santangeli, Robert D. Schaller & Francis E. Marchlinski

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  1. Willy Weng
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Correspondence to Mouhannad M. Sadek.

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The original online version of this article was revised: In this article the author name "Pasquale Santangeli" was incorrectly written as "Pasquale Santangelli".

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Weng, W., Birnie, D.H., Ramirez, F.D. et al. Outcomes of a comprehensive strategy during repeat atrial fibrillation ablation. J Interv Card Electrophysiol 65, 391–399 (2022). https://doi.org/10.1007/s10840-022-01190-4

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