Resumption of Electrical Conduction in Previously Isolated Pulmonary Veins

Abstract

Background-Atrial fibrillation (AF) may recur after pulmonary vein isolation (PVI) as the result of either recurrent PV conduction or non-PV foci. This study characterized the electrophysiological findings of patients with recurrent AF after initially successful PVI and the clinical outcome after a repeat procedure. Methods and Results-Among 185 patients undergoing PVI, 52 reported no significant improvement in their clinical course. We analyzed PV conduction in 51 PVs (15 patients) at repeat PVI. All PVs were isolated with either RF (30 W, 50°C, 60 seconds) or cryoablation (Ϫ80°C for 5 minutes). At repeat study, 42 of the previously isolated 51 PVs had return of conduction. All patients had recurrent conduction in Ն2 PVs, with only 1 non-PV focus identified. The mean number of RF applications required to re-isolate the PVs was fewer at the repeat compared with the initial procedure (10Ϯ6 versus 4Ϯ2, PϽ0.005). Over a period of 15Ϯ6 months, all but 1 patient was clinically improved by the second procedure. Conclusions-In patients with recurrent AF after PVI, return of PV conduction can be expected. Repeat PVI provides significant clinical benefit for these patients. These results suggest that if permanent PV isolation is the ablation strategy, different techniques may be required to improve long-term efficacy.

Vagal Modification can be a Valid Predictor of Late Recurrence of Paroxysmal Atrial Fibrillation Independent of the Pulmonary Vein Isolation Technique

“…However, it has been demonstrated that the cause of AF recurrence after PVI is firstly because of PV conduction recovery, [16][17][18] followed by non-PV AF foci, which are mainly located at the PV antrum. 14,19,20 The major sites of the occurrence of vagal reflexes or ganglionated plexi in the LA are known to be located at the PV ostium and antrum.…”

Can Segmental Pulmonary Vein Ablation Reduce the Recurrence of Atrial Fibrillation When Using a Higher RF Power, Larger Tip Electrode Catheter, and Additional RF Deliveries? The limitations of point-by-point RF ablation

“…3,[7][8][9][10] It has been reported that the completion of a PV electrical disconnection by repeated SOCA can eliminate PAF in spite of a high occurrence of EC recoveries after the SOCA. [7][8][9] Therefore, if a technique to prevent the EC recovery can be designed, the efficacy of the SOCA in PAF can be expected to increase. The findings of the present study have demonstrated the efficacy of SOCA using a technique designed to prevent EC recoveries as well as its limitations.…”

“…In SOCA, frequent recovery of the electrical connections (ECs) between the left atrium and PVs has become the main cause of AF recurrence. 3,4,[7][8][9] We thought that SOCA might be as effective in eliminating PAF as LACA if the EC recoveries could be prevented. Our study on EC recoveries after SOCA suggested that the EC tended to recover at specific sites and a lower RF power might create inadequate RF burns.…”

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…Most studies have reported that patients who fail an initial attempt at ablation and undergo a repeat ablation procedure demonstrate resumption of electrical conduction of the previously isolated PVs rather than new arrhythmogenic foci from non-targeted PVs or outside of the PVs. 263,440,446,1013 This outcome appears to be overwhelmingly the case for the first reablation procedure, whereas in further redo procedures (e.g., second or third redo procedure) other mechanisms also appear to play a more important role. 1014 …”