Redefining the Blanking Period After Catheter Ablation for Paroxysmal Atrial Fibrillation

Abstract

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.

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

“…9 Willems et al showed a strong inverse correlation between the timing of ER within a 3-month blanking period and LR (hazards ratio, 1.84, 4.45, and 9.64, for ER in the first, second, and third month, respectively). 4 Similar results reported Themistoclakis et al in a large nonrandomized study (odds ratio, 20, 54, and 1052 for ER in the first, second, and third month, respectively). 22 In our study, the statistical cut-off showing the highest sensitivity and specificity for late recurrence was 74 days postablation, with a 6-time higher risk of LR.…”

“…Earlier studies reported ER rates between 16% and 65%. 1,4 This large variability might be due to different follow-up strategies using intermittent ECG recordings. Our study, based on results of continuous monitoring, shows a high incidence of ER (57%) during the first 3 months postablation.…”

“…2,3 A three-month blanking period after PVI is used by most of the authors and recommended by the current expert consensus statement. 1,4 The real incidence of ER is underestimated, as most of the data are based on the results of intermittent monitoring using conventional Holter-electrocardiogram (ECG). 5,6 Implantable loop recorders (ILRs) offer the advantage of continuous and long-term monitoring, allowing more accurate follow-up data.…”

“…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. 4 Recent data suggest that electroanatomic changes observed in the left atrium are limited to the first 4 to 8 weeks postablation. 9 Based on data of continuous cardiac monitoring, we sought to investigate the characteristics of ER-associated with LR during follow-up.…”

Left Atrial Appendage Volume and Plasma Docosahexaenoic Acid Levels Are Associated With Atrial Fibrillation Recurrence After Catheter Ablation

“…AF was classified as a paroxysmal AF that self-terminates within 7 days, and persistent AF was classified as that which lasts longer than 7 days or requires termination by cardioversion with drugs or by direct current cardioversion and was classified as longstanding persistent AF when AF continued for more than 1 year. Early recurrence of AF was defined as a recurrence of AF within 3 months of ablation, and was considered transient [1, 15]. AF recurrence was defined as the recurrence of AF episodes or any other atrial tachyarrhythmias lasting more than 30 s, after the 3 months blanking period [1].…”