Recurrent Atrial Fibrillation After Catheter Ablation: Considerations For Repeat Ablation And Strategies To Optimize Success

Abstract

Recurrent AF after catheter ablation occurs in at least 20 to 40% of patients. Repeat ablation is primarily considered for those with symptomatic AF recurrences (often drug-refactory) occurring at least 3 months or more post-ablation. Pulmonary vein reconnection is almost universally encountered, and repeat isolation of electrically connected pulmonary veins should be the primary ablation strategy. Beyond repeat PVI and possible ablation of non-PV triggers, there is little to no evidence that additional substrate modification improves outcomes. In addition to repeat ablation, it is critical to address and treat comorbid conditions which increase arrhythmia risk post-ablation. Specifically, obesity, hypertension, and sleep-disordered breathing should be targeted and modified to increase the likelihood of success.

Keywords: Atrial Fibrillation Ablation; Atrial Fibrillation Lifestyle Modification; Pulmonary Vein Reconnection; Repeat Catheter Ablation.

Figure 1.. Potential ablation strategies during repeat AF procedures: a) repeat pulmonary vein isolation only with confirmation of entrance and exit block from each vein; b) pulmonary vein isolation with ad-ditional linear lesions (posterior wall isolation with linear lesions connecting the superior and infe-rior pulmonary veins; mitral isthmus ablation; +/- right atrial linear lesions); c) pulmonary vein iso-lation and ablation of non-pulmonary vein triggers (i = coronary sinus; ii = LA posterior wall (and left atrial appendage, not pictured); iii = fossa ovalis/interatrial septum; iv = crista terminalis/right atrium; v = superior vena cava)

Figure 2.. Rational approach to a repeat AF ablation procedure

Figure 3.. Illustrative case of a 47 year-old man undergoing repeat catheter ablation for atrial fibrillation. Paroxysmal AF had been diagnosed 2 years prior, and the patient underwent catheter ablation approximately 12 months earlier at another institution. He was AF free for nearly 9 months but then began having recurrent symptoms with paroxysmal AF documented. a) baseline rhythm at the start of the procedure under general anesthesia; frequent short bursts of AF noted; b) dis-played are 3 surface ECG leads and intracardiac recordings from a decapolar catheter in the coronary sinus (labeled cs 9,10 through cs 1,2) and a circular mapping catheter (labeled Las 19,20 through Las 1,2) placed in the right superior pulmonary vein; note the delayed pulmonary vein potential (star) and initiation of AF triggered by spontaneous firing from the RSPV (asterisk); the other 3 PVs remained electrically isolated from the prior procedure; c) electroanatomic map with a posterior view of the left atrium; the RSPV was re-isolated using RF ablation and addition-al tags were placed at sites around the remaining pulmonary veins were there was bipolar volt-age < 0.2 mV and no pace capture; 4) the circular mapping catheter in the right superior pulmo-nary vein demonstrates AF in the RSPV with exit block while the atria remain in sinus rhythm