Recurrent atrial arrhythmias in the setting of chronic pulmonary vein isolation

Abstract

Background: Atrial arrhythmias may still occur in patients after durable pulmonary vein isolation (PVI).

Objective: The purpose of this study was to examine the incidence of patients undergoing ablation for recurrent arrhythmia despite chronic PVI and their clinical outcomes.

Methods: Patients undergoing repeat left atrial ablation procedures were selected from a prospective registry. From this population, we identified patients with chronic PVI. Clinical characteristics, ablation strategies, and outcomes were analyzed.

Results: Between January 2003 and December 2013, 1045 patients underwent 1298 repeat left atrial procedures. Of these, 900 patients had atrial fibrillation (AF) and 145 had atrial flutter (AFL)/atrial tachycardia (AT). Fifty-two patients (5.0%; 27 with AF and 25 with AFL/AT) had chronic PVI and were included in the study. Patients were followed for 19.7 ± 5.6 months. In patients with AF, 11 (41%) had a non-PV trigger identified. Ablation strategies included non-PV trigger ablation (n = 11), empiric trigger-site ablation (n = 3), provoked arrhythmia ablation (n = 9), complex fractionated atrial electrogram ablation (n = 2), and linear ablation (n = 2). During follow-up, 9 (33%) had no recurrence, 7 (26%) had rare AF (≤2 episodes during follow-up ≥1 year), and 11 (41%) had AF recurrence. In patients with AFL/AT, 12 (48%) had no recurrence, 4 (16%) had rare recurrence (≤2 episodes during follow-up ≥1 year), and 9 (36%) had recurrence.

Conclusion: In patients with PVI undergoing a repeat procedure during the time period studied, only a small portion had chronic PVI. A strategy of targeting non-PV triggers for AF and linear/focal ablation for AFL/AT may achieve long-term arrhythmia control in the majority of patients.

Keywords: Atrial fibrillation ablation; Catheter ablation; Complex fractionated atrial electrogram; Pulmonary vein isolation; Triggers.