Repeat Catheter Ablation in Patients with Atrial Arrhythmia Recurrence Despite Durable Pulmonary Vein Isolation

Background: Arrhythmia recurrence after pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) is common and often linked to pulmonary vein reconnection. In patients with arrhythmia recurrences despite durable PVI the optimal ablation approach is unclear. The purpose of the present study was to analyze efficacy of extended ablation maneuvers in these patients and predictors of procedural success. Methods: Consecutive patients with durable PVI undergoing repeat ablation procedures were prospectively enrolled. Patients underwent substrate modification with creation of linear lesions and/or mechanism-specific atrial tachycardia (AT) ablation. 3D-mapping images were analyzed for the presence of left atrial (LA) low-voltage areas according to published scoring systems. Results: Seventy-four patients were analyzed. Mode of recurrence after durable PVI was AF in 27 patients (36.5%) and AT in 47 patients (63.5%). Linear lesion ablation was performed in 60 patients (81.1%). Twenty-four patients (32.4%) were treated for focal AT mechanisms. Mean follow-up was 565{plus minus}342 days. Estimated arrhythmia-free survival after 24 months was significantly higher in patients with AT than in patients with AF as mode of recurrence after durable PVI (42.9{plus minus}8.2% vs. 24.7{plus minus}8.5%, p=0.023) and in patients without compared to patients with marked LA low-voltage areas (40.5{plus minus}9.2% vs. 22.8{plus minus}8.5%, p=0.041). The mode of recurrence after durable PVI was the only independent predictor of further arrhythmia recurrence after repeat ablation. Conclusion: Arrhythmia-free survival following repeat ablation procedures in patients with durable PVI highly depends on mode of arrhythmia recurrence and the presence of LA low-voltage areas.