Early recurrence of atrial arrhythmias following pulmonary vein antral isolation: Timing and frequency of early recurrences predicts long-term ablation success

Liang, Jackson J.; Elafros, Melissa A.; Chik, W.; Santangeli, Pasquale; Zado, Erica S.; Frankel, David S.; Supple, Gregory E.; Schaller, Robert D.; Lin, David; Hutchinson, Mathew D.; Riley, Michael P.; Callans, David J.; Marchlinski, Francis E.; Dixit, Sanjay

doi:10.1016/j.hrthm.2015.07.015

Cited by 72 publications

(59 citation statements)

References 27 publications

(21 reference statements)

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“…2,5 These include clinical characteristics, pattern of AF, echocardiographic parameters, such as LA enlargement, markers of inflammation, and procedural characteristics. In this study, a lower prevalence of ER was independently associated with smaller LA size, an ablation strategy of eliminating dormant PV conduction, and the use of ACEi or ARB at discharge.…”

Section: Predictors Of Er After Af Ablationmentioning

confidence: 99%

“…1 Notably, during the first 3 months after ablation, a substantial proportion of patients experience early recurrences (ERs) of atrial tachyarrhythmias (ATs). [2][3][4][5] The relevance of ER to long-term recurrence risk is controversial; ERs are believed to often be because of transient local inflammatory states unassociated with the risk of later AF recurrence, and thus do not necessarily represent treatment failure. 3,4,6 It has, therefore, become common practice to use a periprocedural blanking period, during which recurrences are considered nonspecific and do not prompt reintervention.…”

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confidence: 99%

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Redefining the Blanking Period After Catheter Ablation for Paroxysmal Atrial Fibrillation

Willems¹,

Khairy²,

Andrade³

et al. 2016

Circ: Arrhythmia and Electrophysiology

124

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Background-Early recurrences (ERs) of atrial tachyarrhythmia are common after catheter ablation of atrial fibrillation. A 3-month blanking period is recommended by current guidelines. This study sought to investigate the significance of ER during the first 3 months post ablation in predicting late recurrences and determine whether it varies according to timing. Methods and Results-A total of 401 patients with paroxysmal atrial fibrillation undergoing pulmonary vein isolation were followed for 12 months with transtelephonic monitoring in the ADVICE (Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination) trial. Patients with atrial tachyarrhythmia ≥30 s within the 3-month blanking period were stratified according to the timing of ER. A total of 179 patients (44.6%) experienced their last episode of ER during the first (n=53), second (n=44), or third (n=82) month of the 3-month blanking period. One-year freedom from symptomatic atrial tachyarrhythmia was 77.2% in patients without ER compared with 62.6%, 36.4%, and 7.8% in patients with ER 1, 2, and 3 months post ablation, respectively (P<0.0001). Receiver operating curve analyses revealed a strong correlation between the timing of ER and late recurrence (area under the curve 0.82, P<0.0001). Corresponding hazard ratios for ER during the first, second, and third months were 1.84, 4.45, and 9.64, respectively. Conclusions-This study validates the use of a blanking period after catheter ablation for paroxysmal atrial fibrillation but calls into question the 90-day cut-off value. In particular, >90% of patients with ER during the third month post ablation experience late recurrence by 1 year. However, pending further study, repeat ablation before 90 days cannot be routinely advocated. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01058980.(Circ Arrhythm Electrophysiol. 2016;9:e003909.

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Section: Predictors Of Er After Af Ablationmentioning

confidence: 99%

mentioning

confidence: 99%

Redefining the Blanking Period After Catheter Ablation for Paroxysmal Atrial Fibrillation

Willems¹,

Khairy²,

Andrade³

et al. 2016

Circ: Arrhythmia and Electrophysiology

124

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“…As we have previously reported, we chose 6 weeks as the censor period to delineate ERAA because that was when patients routinely return for their first postablation followup. 11 We define any arrhythmia events beyond the first clinic visit (at 6 weeks) as late recurrence, and these were typically diagnosed either on routine or symptom-driven electrocardiograms, Holter monitoring, or TTM. At each follow-up visit, patients with pacemakers or implantable cardioverter defibrillators had their devices interrogated for atrial high-rate episodes and those with episodes lasting ≥30 seconds in duration were considered to have sustained arrhythmia recurrence.…”

Section: Early Versus Late Recurrences Of Atrial Arrhythmiasmentioning

confidence: 99%

Pulmonary Vein Antral Isolation and Nonpulmonary Vein Trigger Ablation Are Sufficient to Achieve Favorable Long-Term Outcomes Including Transformation to Paroxysmal Arrhythmias in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Liang¹,

Elafros²,

Muser³

et al. 2016

Circ: Arrhythmia and Electrophysiology

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A lthough pulmonary vein isolation (PVI) is well accepted to be the cornerstone of ablation for paroxysmal atrial fibrillation (AF), there remains lack of consensus on the optimal ablation strategy in patients with persistent and longstanding persistent AF. [1][2][3] Although an ablation strategy limited primarily to PVI, with or without targeting of documented nonpulmonary vein (PV) triggers, results in lower long-term AF-free survival rates in patients with persistent and longstanding persistent AF than paroxysmal AF, outcomes are not improved with more extensive substrate modification strategies.2,3 It has been shown that ≈50% of patients with persistent and long-standing persistent AF who undergo extensive substrate modification experience persistent organized atrial tachyarrhythmias (OAT) after ablation. 4,5 In contrast, patients with persistent and long-standing persistent AF treated with a more targeted ablation strategy (PVI with or without documented non-PV trigger ablation) are more likely to experience arrhythmia recurrences in the form of AF instead of OATs. However, when the arrhythmia recurrence in these patients is paroxysmal in nature, this likely suggests a favorable modification of the underlying AF substrate, which becomes less capable of sustaining AF.The objective of this study, therefore, was to determine the nature of initial arrhythmia recurrence in patients with © 2016 American Heart Association, Inc. Original ArticleBackground-Transformation from persistent to paroxysmal atrial fibrillation (AF) after ablation suggests modification of the underlying substrate. We examined the nature of initial arrhythmia recurrence in patients with nonparoxysmal AF undergoing antral pulmonary vein isolation and nonpulmonary vein trigger ablation and correlated recurrence type with long-term ablation efficacy after the last procedure. Methods and Results-Three hundred and seventeen consecutive patients with persistent (n=200) and long-standing persistent (n=117) AF undergoing first ablation were included. AF recurrence was defined as early (≤6 weeks) or late (>6 weeks after ablation) and paroxysmal (either spontaneous conversion or treated with cardioversion ≤7 days) or persistent (lasting >7 days). During median follow-up of 29.8 (interquartile range: 14.8-49.9) months, 221 patients had ≥1 recurrence. Initial recurrence was paroxysmal in 169 patients (76%) and persistent in 52 patients (24%). Patients experiencing paroxysmal (versus persistent) initial recurrence were more likely to achieve long-term freedom off antiarrhythmic drugs (hazard ratio, 2.2; 95% confidence interval, 1.5-3.2; P<0.0001), freedom on/off antiarrhythmic drugs (hazard ratio, 2.5; 95% confidence interval, 1.6-3.8; P<0.0001), and arrhythmia control (hazard ratio, 5.2; 95% confidence interval, 2.9-9.2; P<0.0001) after last ablation. Conclusions-In patients with persistent and long-standing persistent AF, limited ablation targeting pulmonary veins and documented nonpulmonary vein triggers improves the maintenance of sinus rhythm and re...

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“…Though early AF recurrence is not a favorable sign, recurrence within 3 months is multifactorial and does not necessarily indicate long-term failure. 5 Of note, there is an unusually high rate of early recurrence in this study-even if only the optimal strategy is considered, 62% had early recurrence. Two recent studies using regular irrigated radiofrequency observed early recurrence in 33.5% (in the control arm) 6 and 46% (among the paroxysmal group).…”

Section: Does the Gap-af Trial Settle Controversymentioning

confidence: 61%

“…Two recent studies using regular irrigated radiofrequency observed early recurrence in 33.5% (in the control arm) 6 and 46% (among the paroxysmal group). 5 Das et al 7 presented a small study using force-sensing catheters that demonstrated an early recurrence rate of 43%.…”

Section: Does the Gap-af Trial Settle Controversymentioning

confidence: 99%

The Tribulations of Atrial Fibrillation Ablation Trialists

Sauer

Callans

2016

Circ: Arrhythmia and Electrophysiology

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Early recurrence of atrial arrhythmias following pulmonary vein antral isolation: Timing and frequency of early recurrences predicts long-term ablation success

Cited by 72 publications

References 27 publications

Redefining the Blanking Period After Catheter Ablation for Paroxysmal Atrial Fibrillation

Redefining the Blanking Period After Catheter Ablation for Paroxysmal Atrial Fibrillation

Pulmonary Vein Antral Isolation and Nonpulmonary Vein Trigger Ablation Are Sufficient to Achieve Favorable Long-Term Outcomes Including Transformation to Paroxysmal Arrhythmias in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

The Tribulations of Atrial Fibrillation Ablation Trialists

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