Recurrences of Atrial Fibrillation Despite Durable Pulmonary Vein Isolation: The PARTY-PVI Study

Abstract

BACKGROUND: Recurrences of atrial fibrillation (AF) after pulmonary vein isolation (PVI) are mainly due to pulmonary vein reconnection. However, a growing number of patients have AF recurrences despite durable PVI. The optimal ablative strategy for these patients is unknown. We analyzed the impact of current ablation strategies in a large multicenter study. METHODS: Patients undergoing a redo ablation for AF and presenting durable PVI were included. The freedom from atrial arrhythmia after pulmonary vein-based, linear-based, electrogram-based, and trigger-based ablation strategies were compared. RESULTS: Between 2010 and 2020, 367 patients (67% men, 63±10 years, 44% paroxysmal) underwent a redo ablation for AF recurrences despite durable PVI at 39 centers. After durable PVI was confirmed, linear-based ablation was performed in 219 (60%) patients, electrogram-based ablation in 168 (45%) patients, trigger-based ablation in 101 (27%) patients, and pulmonary vein-based ablation in 56 (15%) patients. Seven patients (2%) did not undergo any additional ablation during the redo procedure. After 22±19 months of follow-up, 122 (33%) and 159 (43%) patients had a recurrence of atrial arrhythmia at 12 and 24 months, respectively. No significant difference in arrhythmia-free survival was observed between the different ablation strategies. Left atrial dilatation was the only independent factor associated with arrhythmia-free survival (HR, 1.59 [95% CI, 1.13–2.23]; P =0.006). CONCLUSIONS: In patients with recurrent AF despite durable PVI, no ablation strategy used alone or in combination during the redo procedure appears to be superior in improving arrhythmia-free survival. Left atrial size is a significant predictor of ablation outcome in this population.

Predictors of pulmonary vein non‐reconnection in the second procedure after ablation index‐guided pulmonary vein isolation for atrial fibrillation and its impact on the outcome

“…Several extra‐PV ablation strategies have been proposed to improve the outcome of ablation procedures for these patients. However, no extra‐PV ablation strategies effectively enhanced the result of the AF ablation procedure for patients with durable PVI 20 . Further studies were needed to explore the ablation strategies to improve the outcome of the ablation procedure for these patients.…”

“…Additional CFAE ablation to PVI was reported to increase postablation atrial tachycardia recurrence in AF ablation. [20][21][22] CFAE ablation might deteriorate the outcome of AF ablation in patients with PV non-reconnection. However, we performed a multivariate Cox proportional hazard model analysis and concluded that CFAE ablation was not an independent predictor of AT recurrence after the second procedure.…”

“…In particular, CFAE ablation was more frequently performed in the PV non‐reconnection group. Additional CFAE ablation to PVI was reported to increase postablation atrial tachycardia recurrence in AF ablation 20–22 . CFAE ablation might deteriorate the outcome of AF ablation in patients with PV non‐reconnection.…”

Spatial autocorrelation dimension as a potential determinant for the temporal persistence of human atrial and ventricular fibrillation

“…Despite extensive research, the optimal approach to electrophysiologically characterise human fibrillatory dynamics remains incompletely defined. At present, in AF in particular, fundamental challenges remain such as why AF progresses from paroxysmal to persistent in some but not all patients, 10 why a proportion of patients respond to anti-AF medicines but others do not, 27 why AF persists despite durable pulmonary vein isolation in some patients, 8,9 and why substrate and linear ablation has not led to dramatically improved clinical outcomes. 28 These problems have led many in the clinical field to suggest that understanding of the biophysical processes sustaining fibrillation is not complete, providing an important rationale to support the exploration of new strategies for electrophysiologic characterization of human fibrillatory dynamics.…”

“…Such a general paradigm, if it could be developed, would have significant practical relevance, as it could potentially inform unresolved contemporary clinical questions. Examples of such challenges could include the persistence of AF despite pulmonary vein isolation 8,9 , the upper limit of effectiveness observed with PVI, 8,9 objective delineation of paroxysmal from persistent forms of AF, 10 or understanding why some episodes of VF are responsive or unresponsive to defibrillation shocks. 11 Here, we sought to contribute to efforts to develop a conceptual paradigm, to account for the potential for episodes of fibrillation to either persist or self-terminate.…”