Recurrence of Atrial Tachyarrhythmia During the Second Month of the Blanking Period Is Associated With More Extensive Pulmonary Vein Reconnection at Repeat Electrophysiology Study

Abstract

Background-Current guidelines recommend a 3-month blanking period after pulmonary vein isolation (PVI) as early recurrence of atrial tachyarrhythmia (ERAT) may be due to transient proarrhythmic factors. However, studies have suggested that these factors resolve by 1 month. PV reconnection (PVrc) is strongly associated with postblanking AT recurrence in paroxysmal atrial fibrillation. We hypothesized that ERAT occurring beyond 4 weeks after PVI is associated with PVrc at repeat electrophysiology study. Methods and Results-Forty patients with paroxysmal atrial fibrillation underwent mandatory repeat electrophysiology study 2 months after PVI, regardless of symptoms, to document the number of reconnected PVs. Antiarrhythmic drugs, including β-blockers, were discontinued 4 weeks after PVI. Patients were instructed to record a 30-second ECG everyday between the 2 procedures using a portable monitor, with additional recordings for symptoms. ERAT was defined as ≥30 seconds of AT. Patients recorded a total of 3293 ECGs. Four (10%) patients had ERAT in the first 4 weeks (M1) only, 2 (5%) in month 2 (M2) only, and 11 (28%) in both. PVrc of 1 PV was identified in 12 (30%) patients and of >1 PV in 13 (32%) patients. ERAT in M2 was associated with PVrc, whereas M1 was not (11/

Redefining the Blanking Period After Catheter Ablation for Paroxysmal Atrial Fibrillation

“…Mechanistically, a 50-day blanking period is coherent with recent data suggesting that 4 to 8 weeks are required for the completion of LA electroanatomic changes post ablation. 9 From a practical perspective, our findings may inform management decisions about ER after AF ablation. Recurrences within the third month post ablation should not be considered nonspecific because the overwhelming majority (>90%) of such patients will subsequently experience recurrent AT.…”

“…1 However, there is limited evidence on the impact of ER-timing within the blanking period on clinical outcomes. [7][8][9] Although the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society expert consensus recommends a 3 month post procedural blanking period, emerging data suggest that electroanatomic changes observed in the left atrium are limited to the first 4 to 8 weeks post ablation. 9 The ADVICE (Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination) study was designed to determine the use of an adenosine-guided…”

Mechanisms and clinical significance of early recurrences of atrial arrhythmias after catheter ablation for atrial fibrillation

“…Das et al[27] examined the association between timing of ERAA with the likelihood of PV reconnection at repeat electrophysiology study in 40 patients with nonparoxysmal AF treated with PVI. After the index ablation procedure, all 40 patients were brought back for electrophysiology study regardless of whether they had recurrence post-ablation.…”

Characteristics of early recurrences detected by continuous cardiac monitoring influencing the long‐term outcome after atrial fibrillation ablation

“…Recurrences at the end of the blanking period are more likely to represent PV reconnection, as opposed to acute inflammatory or remodeling effects . In this respect, Das et al could show that patients undergoing systematic PV mapping 2 months postablation the ER in the second month after PVI was strongly associated with PV reconnection, as opposed to ER confined to the first month …”

“…Indeed, results from the ADVICE trial have shown that most patients with ER during the third‐month post‐ablation experience late recurrence (LR) by 1 year . Recent data suggest that electroanatomic changes observed in the left atrium are limited to the first 4 to 8 weeks postablation …”