How Long After Ablation Surgery Do You Know if You Will Have Afib Again
Introduction
See Editorial by Yamaguchi and Marrouche
WHAT IS KNOWN?
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Arrhythmia recurrences afterwards atrial fibrillation ablation procedures remain problematic.
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In the setting of early recurrences afterwards atrial fibrillation ablation, reconnection of one or more of the previously ablated pulmonary veins is thought to exist the culprit and repeat ablations provided incremental benefit for rhythm control.
WHAT THE STUDY ADDS?
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Pulmonary vein reconnection is the most common electrophysiological finding in patients with atrial fibrillation recurrence after initial long-term success (defined as ≥36 months without antiarrhythmics use), but with lower rates than what has been reported for early recurrences.
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Repeat ablations in the setting of atrial fibrillation recurrence after long-term ablation success involve complex ablation approaches to reisolate the pulmonary veins, extend antral ablations, and modify the atrial substrate and are associated with adequate success rates.
Atrial fibrillation (AF) is the nigh mutual tachyarrhythmia in clinical exercise and has been associated with increased morbidity and mortality.i Catheter-based pulmonary vein (PV) isolation is a well-established handling strategy for drug-refractory AF and an acceptable first-line therapy in paroxysmal AF.2,3
Long-term success of AF ablation procedures, defined as freedom from arrhythmia recurrence for a minimum of 36 months off antiarrhythmic therapy, can be achieved in many patients.4,5 Although nearly arrhythmia recurrences typically occur in the first vi months to 1 year after ablation,v–seven AF recurrences, after initially achieving long-term success, have been reported. In the setting of early recurrences, reconnection of ane or more of the previously ablated PV has been oftentimes described5,8 and echo ablations provided incremental do good for rhythm command.5 Nonetheless, piddling is known well-nigh the electrophysiological characteristics and outcomes of repeat ablations in patients with initial long-term success and very belatedly arrhythmia recurrences. More than specifically, little is known well-nigh PV reconnection rates in this setting and non-PV ablation targets, especially in patients in whom the PVs had remained isolated from prior ablation. In today'southward clinical practise, electrophysiologists oft face such scenarios which represent both clinical and procedural challenges.
In this study, we aim to describe the electrophysiological findings and outcomes of repeat ablation procedures in patients with recurrent arrhythmia subsequently initial long-term success of AF ablation.
Methods
The data, analytic methods, and study materials will not be fabricated bachelor to other researchers for purposes of reproducing the results or replicating the procedure.
Study Population
All consecutive patients who underwent AF ablation at our institution betwixt January 2000 and Dec 2015 were enrolled in a prospectively maintained data registry. From this registry, nosotros only included patients who had AF recurrence after initially achieving long-term success with ≥1 ablation procedures, then underwent repeat ablation for recurrent arrhythmia. Nosotros defined long-term success as liberty from AF recurrence across the 3-month blanking period, for a minimum of 36 months from the date of the last ablation procedure. Patients who required either electric cardioversion or antiarrhythmic drug therapy to achieve freedom from arrhythmia across the blanking menses and before 36 months post-ablation were excluded. A total of 137 patients met our inclusion criteria. The study protocol was approved by Cleveland Dispensary institutional review board.
Radiofrequency Ablation Protocol
Our AF ablation protocol and periprocedural anticoagulation strategies were described previously in detail.9,x Antiarrhythmics were stopped four to v half-lives before ablation whenever possible and depending on the clinical scenario. All patients were therapeutically anticoagulated when they underwent the ablation process.
An intravascular ultrasound placed in the right atrium was used to aid in performing trans-septal puncture, to guide catheter manipulation and assess for catheter–tissue contact during ablation, and was to monitor for complications during the procedure. A round mapping catheter (Lasso) was used to assess PV antral potentials and to guide both PV and non-PV ablations to ensure continuity of the ablation lines and absence of gaps. The ablation procedures targeted mainly reisolation of PVs where conduction recovery was detected, as well as substrate modification which included the posterior wall, septal to the right PVs, roof, appendage, coronary sinus, superior vena cava, in addition to left atrial palpitate (AFL) ablations when clinically applicative and at the discretion of the operator. In superior vena cava ablations, pacing and assessment for phrenic nerve stimulation was performed before any ablation energy application.
The decision to perform mapping and ablation in sinus rhythm afterwards electrical cardioversion or in AF was up to the operator. Patients who remained in AF after ablation underwent electric cardioversion to sinus rhythm followed by confirmation of isolation of the PVs and adequate ablation of non-PV targets. Boosted ablation in sinus rhythm was performed when needed.
In patients in whom the PVs were found to have remained isolated from prior ablations, isoproterenol infusion up to 20 μg/min and upwardly to 10 minutes was used to appraise for not-PV triggers and these were targeted with ablation. Blood pressure level was closely monitored during infusions, and isoproterenol was stopped when a astringent hypotensive response occurred.
For all patients with a history of typical AFL, a cavotricuspid isthmus line was performed with confirmation of bidirectional cake equally an end indicate.
Postal service-Ablation Follow-Upwardly Protocol
In all patients, clinical data were collected earlier the ablation procedures, during follow-up visits, and from all other forms of encounters with the patients or their referring physicians, including phone calls and clinical letters, and continuously updated using our establishment's electronic medical records. Post-ablation, patients were ordinarily hospitalized overnight and discharged on the post-obit day, whenever appropriate. Clinical follow-up visits and 12-lead ECG were scheduled at 3, 6, and 12 months post-procedure and on a yearly basis thereafter. More frequent follow-up visits were scheduled equally needed for patients with recurrent arrhythmia and for those who had symptoms or required close management of their long-term anticoagulation. All patients were provided with rhythm transmitters and were instructed to ship transtelephonic ECG transmissions on a weekly footing and whenever symptomatic for a minimum of iii months later on the procedure. Additional event monitoring was obtained beyond the three-month period for patients with documented arrhythmia and those who developed symptoms suggestive of arrhythmia during this fourth dimension period. Holter monitor recordings were obtained in patients who were suspected to have arrhythmia recurrences simply had no electrocardiographic documentation. Interrogation of implanted devices, whenever available, was likewise used to assess for arrhythmia recurrence. Recurrence was defined as an episode of atrial arrhythmia beyond the beginning 3 months postal service-ablation (blanking menstruation), lasting for 30 s or more than, documented on 12-lead ECG, event or Holter monitor, or during interrogation of implanted devices.
Antiarrhythmic medications were typically prescribed for 3 months postal service-ablation (during the blanking period). Patients were more often than not taken off antiarrhythmic medications later on success of redo ablations, merely in some situations in a shared medical decision process, these were continued and no attempts were fabricated to discontinue them when patients were doing clinically well without documented arrhythmia beyond the blanking period. For those who continued to have recurrences, either antiarrhythmic or additional ablation procedures were offered.
Clinical Outcomes
The outcomes of interest were assessed for redo ablations performed after initial long-term success of AF ablation procedures. The findings and outcomes of interest were (1) the electrophysiological findings during the first ablation afterwards long-term success and (2) success at last follow-upwards, with ane or multiple ablations, divers equally freedom from arrhythmia recurrence.
Statistical Analysis
All descriptive statistics were obtained past using the statistical software JMP pro version x.0 (SAS, NC). Continuous variables are presented as hateful values and SD or median and quartiles, as appropriate. Categorical variables are presented every bit north (%).
Results
Between 2000 and 2015, 10 378 patients underwent AF ablation procedures at our institution, of which 137 had repeat ablation for AF recurrence after achieving long-term success, and were included in this written report.
The baseline characteristics of the study population are shown in Table. The mean age was 63.5±8.8 years, and 73% were male patients. The median arrhythmia-gratuitous flow after initial ablation, which defined long-term success, was 52 months (41–68 months). The latter was achieved after 1, ii, or iii prior ablations in 101 (74%), 28 (20%), and 8 (half dozen%) patients, respectively. The targeted AF was persistent in 42.three% and paroxysmal AF in 57.7% of them. Our initial ablation strategy typically involves antral PV isolation with a lasso-guided approach, and in most patients, specially those with persistent AF, posterior wall ablation. In 36 patients, >1 ablation procedure was initially required to reach long-term success. In these additional ablation procedures, PV antral ablations targeted areas of electrical recovery at the left superior, left junior, right superior, and right inferior PVs in 32 (88.nine%), 27 (75%), 28 (77.vii%), and 32 (88.9%) patients, respectively. Boosted ablations to the superior vena cava, posterior wall, inferior to right PVs, coronary sinus, and cavotricuspid isthmus were performed in 21 (58%), 12 (33%), 7 (19%), 2 (half-dozen%), 4 (11%), and 9 (25%) patients, respectively.
| Characteristics | North=137 (%) |
|---|---|
| Historic period, y | 63.v±8.8 |
| Male sex | 100 (73) |
| Atrial fibrillation type | |
| Persistent | 58 (42.3%) |
| Paroxysmal | 79 (57.7%) |
| Race, white | 44 (32) |
| Body mass alphabetize, kg/grand2 | 30.2±6.25 |
| Coronary artery illness | 24 (18) |
| Hypertension | 28 (xx) |
| Diabetes mellitus | 4 (3) |
| Chronic obstructive pulmonary disease | 2 (1) |
| Prior pacemaker | five (four) |
| Smoking history | 64 (47) |
| Left ventricular ejection fraction, % | 54.nine±7.7 |
| Duration of long-term success, mo | 56.6±xviii.9 |
| No. of ablations needed to achieve long-term success | |
| 1 | 101 (73.7) |
| 2 | 28 (20.40) |
| 3 | viii (5.fourscore) |
| Rhythm at presentation for redo ablation | |
| Sinus rhythm | 92 (67.i%) |
| Atrial fibrillation | 32 (23.three%) |
| Atrial flutter | ten (7.3%) |
| Atrially paced | two (1.4%) |
Electrophysiological Findings During Redo Ablation After Initial Long-Term Ablation Success
Out of 137 patients who underwent redo ablation procedures after initial long-term AF ablation success, 67.i% presented in sinus rhythm on the solar day of repeat ablation, whereas 23.iii% presented in AF, vii.iii% in AFL, and the remaining i.4% in atrially paced rhythm (Tabular array). During the ablation process after initial long-term success, reconnection along the antra of at least one of the previously ablated PVs was plant in 111 (81%) patients. Reconnection along a left superior, left inferior, left mutual, right superior, right inferior, and correct common PV was found in 88 (64%), 85 (62%), 18 (13%), 69 (50%), 74 (54%), and iv (2.9%) patients, respectively. Additional non-PV ablations were performed in 127 (92.7%) patients and were every bit follows: posterior wall (46%), septal to right PVs (49%), inferior to correct PVs (34%), superior vena cava (35%), coronary sinus (16%), left atrial appendage (15%) and lines at the roof (52%), left junior PV to mitral annulus (xv%), right superior PV to mitral annulus (10%), and cavotricuspid isthmus ablation (33%; Figure i).
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Figure i. Electrophysiological findings of redo ablation in patients where at to the lowest degree 1 pulmonary vein (PV) reconnection was detected later on a menses of long-term success. CTI indicates cavotricuspid isthmus; LAA, left atrial bagginess; LC, left mutual; LI, left inferior; LS, left superior; MA, mitral annulus; RC, right common; RI, right junior; and RS, right superior.
In patients without any PV reconnections (xix%), ablations were performed at the posterior wall (30.8%), roof (53.8%), inferior to right inferior PV (26.9%), septal to right PV (42.three%), coronary sinus (7.7%), left inferior PV to mitral annulus (26.ix%), right superior PV to mitral annulus (xv.4%), left atrial appendage (23%), and cavotricuspid isthmus (46%; Figure two).
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Figure 2. Electrophysiological findings of redo ablation in patients where no pulmonary vein (PV) reconnection was detected after a period of long-term success. CTI indicates cavotricuspid isthmus; LAA, left atrial appendage; LI, left inferior; MA, mitral annulus; RI, right junior; RPV, right pulmonary vein; and RS, correct superior.
Outcomes of Repeat Ablation After Initial Long-Term AF Ablation Success
After a 3-month blanking menstruum, 49 (36%) patients had documented arrhythmia recurrence, of which 47 (34%) were symptomatic. Recurrent arrhythmias were AF in 35 (71%) patients, AFL in 9 (18%), and a combination of both in 5 (ten%). The median fourth dimension to recurrence was 13.3 months (five.3–32.5 months). Additional ablation procedures were performed in nineteen patients (14%) 14.7 months (six.5–35.v months) later.
The total number of repeat ablation procedures subsequently initial long-term success was 1 in 118 patients, 2 in xv patients, and 3 in the remaining four patients.
After a median follow-up of 17 months (5–36.9 months) after the concluding ablation process, 103 patients (75%) were arrhythmia gratuitous (79 off antiarrhythmics, 24 on antiarrhythmics). Of the patients who did non have any PV reconnections on redo ablation after initial long-term success (n=26), 10 (38%) had arrhythmia recurrence (7 AF, 3 AFL) and 16 (62%) remained free from arrhythmia on follow-up (thirteen off antiarrhythmics, 3 on antiarrhythmics).
Complications from the echo ablation procedures (n=160) occurred in iv patients (ii.5%). Two (ane.25%) patients had PV stenosis. One of them had astringent stenosis of left superior PV requiring stenting and other had severe stenosis of left inferior PV which besides required stenting. Pericardial tamponade requiring pericardiocentesis occurred in i (0.vi%). Local infection (prostatitis) occurred in i (0.half-dozen%) patient. No deaths occurred equally a result of these complications.
Give-and-take
The current study assessed the electrophysiological findings and repeat ablation procedures outcomes in patients with arrhythmia recurrence after initially achieving long-term success with ≥1 previous AF ablation procedures. AF recurrences despite achieving long-term success (at least 36 months mail service-ablation) have been reported,eleven,12 even so non well studied in terms of pathophysiology and treatment outcomes. To the all-time of our knowledge, this is the largest study to-appointment to evaluate the electrophysiological findings and the outcomes of repeat ablation in this setting.
An important and interesting finding is that in patients with arrhythmia recurrence later long-term success, PV reconnection of at to the lowest degree ane of the PVs remains very common (81%), but with lower rates than what had been reported for early recurrences.five In our feel, repeat ablations in these patients involve complex ablation strategies aiming at reisolation of the PVs, extension of previous antral ablations, and modification of the atrial substrate, eventually leading to adequate rates of freedom from atrial tachyarrhythmias.
Our written report results shed lite on the importance of the substrate-trigger interplay in the pathophysiology of AF recurrence. The long-term success achieved with prior ablation procedures in this patient population implies that effective and durable PV isolation was attained. Even so, very late recurrences in this setting were all the same associated with a high prevalence of reconnection along at least i of the previously ablated PVs. The reconnection of PVs despite ensuring proper isolation during initial ablation procedures has been previously described. Although in many cases information technology could exist related to gaps in ablation lines, acute edema, or lack of transmural lesions, PV conduction recovery has been reported after surgical ablations. For instance, a report from our group investigating AF mechanisms in lung transplantation recipients demonstrated evidence of electrical conduction recovery after surgical resection and anastomosis of the PVs, which may be considered as the ultimate class of PV isolation.13
Although PV reconnection has been shown to be the primary electrophysiological finding in early recurrences and repeat ablation with PV reisolation has been shown to be incrementally beneficial,vii the exact mechanisms of the electrical reconnection remain unknown. The timing of PV conduction recovery in the electric current study'due south population is also difficult to decide simply is likely to have occurred early after the index ablation procedures and it is possible that progression of the substrate occurred over time, eventually leading to recurrences. On the other mitt, the observation of high rates of PV reconnection does not imply a crusade and effect relationship in the pathophysiology of recurrent arrhythmias. Although reisolation of the PVs was performed whenever reconnection was detected in improver to extension of ablations around the PV antra and substrate modification, there was just a small incremental freedom from AF during follow-upwardly in patients who required reisolation of the PVs versus those who did not. This hypothetically implies that the atrial substrate plays an important function in orchestrating arrhythmia recurrences after initial long-term success. Efforts aiming at better substrate label, for example, using cardiac magnetic resonance imaging, may be associated with improved ablation outcomes in this setting. This hypothesis is currently being tested in the ongoing DECAAFII trial (Efficacy of Delayed Enhancement MRI-Guided Ablation Versus Conventional Catheter Ablation of Atrial Fibrillation; URL: http://world wide web.clinicaltrials.gov. Unique identifier: NCT02529319).
Report Limitations
The written report has the inherent limitations of observational studies. It was performed retrospectively; however, the identification of the study population and almost of data drove was derived from a prospectively maintained registry. The lack of a control group limits the estimation of the electrophysiological findings in the context of clinical recurrence; however, it is practically challenging to get invasive electrophysiological data in patients without clinical arrhythmia recurrence. Another limitation is that formal substrate assessment using voltage mapping or avant-garde imaging such as cardiac magnetic resonance imaging was not performed. Nonetheless, afterwards an anatomic-based approach, we were able to accomplish proficient outcomes. It is possible that formal substrate assessment using the above-mentioned methods could accept improved the ablation outcomes. AF recurrences were defined based on documentations on ECG or telemonitors done at routine intervals or when triggered by patients' symptoms, hence, asymptomatic AF recurrences may accept been missed and that is a common limitation to most AF ablation issue studies. It would be difficult to ascertain the number of missed events in each subgroup; however, information technology would exist reasonable to assume that both groups would have been equally affected past these events. This group of patients had documented recurrence and was brought to the laboratory for redo primarily considering of symptoms. Finally, the study was conducted in a big tertiary care referral center, and AF ablations were performed past experienced operators, which may limit the generalizability of the results to lower volume centers and operators.
Conclusions
PV reconnection is the most common electrophysiological finding in patients with AF recurrence after initial long-term success, only with lower rates than what had been reported for early recurrences. In our experience, repeat ablations in this setting involve complex ablation approaches to reisolate the PVs, extend antral ablations, and modify the atrial substrate and are associated with acceptable success rates.
Footnotes
References
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Source: https://www.ahajournals.org/doi/10.1161/circep.117.005785
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