Recurrence Post-Atrial Fibrillation Ablation: Think Outside the Pulmonary Veins

See Article by Shah et al The initiation and maintenance of atrial fibrillation (AF) require triggers and a vulnerable atrial substrate. AF often progresses from paroxysmal and trigger-driven arrhythmias to persistent and more substrate-dependent arrhythmias. After the seminal work by Haissaguerre et al1 who demonstrated that ectopic beats from the pulmonary vein (PV) often trigger AF, catheter ablation of AF has focused on electrical isolation of the PV. PV isolation (PVI) has demonstrated a 60% to 80% success rate of maintaining sinus rhythm in patients with paroxysmal AF.2 Even in nonparoxysmal AF patients, PVI alone conveys a 40% to 50% rate of success.2,3 The current 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement describes permanent electrical isolation of the PVs as a cornerstone of AF ablation.2 Despite the advancement of ablation technology such as contact force sensing and cryoballoon technology, PV electrical reconnection is frequently observed. Jiang et al4 studied the incidence of PV reconnection in 32 patients free from AF recurrence at 12 months postradiofrequency ablation: PV reconnection was observed in 29 patients (90.6%). Recently, Nery et al5 analyzed the relationship between PV reconnection and freedom from AF in their meta-analysis including studies using radiofrequency ablation, cryoballoon ablation, and laser balloon ablation. Among patients with and without AF recurrence, 86% and 59% had at least 1 PV reconnection, respectively. The average follow-up periods of the studies included in this meta-analysis were 8±10 months. Durable PVI is associated with a lower risk of AF recurrence; however, the association was modest. Analyses of studies that included exclusively patients with paroxysmal AF in this meta-analysis showed that the association was not statistically significant. Miyazaki et al6 reported that PV reconnection was detected in 65% of patients after second-generation cryoballoon ablation at a median of 6 months …