Atrial fibrillation patients with isolated pulmonary veins: Is sinus rhythm achievable?

Judit Szilágyi, Gregory M. Marcus, Nitish Badhwar, Byron K. Lee, Randall J. Lee, Vasanth Vedantham, Zian H. Tseng, Tomos Walters, Melvin Scheinman, Jeffrey Olgin, Edward P. Gerstenfeld

The cornerstone of atrial fibrillation (AF) ablation is isolation of the pulmonary veins (PVs). Patients with recurrent AF undergoing repeat ablation usually have PV reconnection (PVr). The ablation strategy and outcome of patients undergoing repeat ablation who have persistent isolation of all PVs (PVi) at the time of repeat ablation is unknown. We studied consecutive patients with recurrent AF undergoing repeat ablation and compared patients with PVi to those with PVr. One hundred fifty-two patients underwent repeat ablation, and of these, 25 patients (16.4%) had PVi. Patients with PVi underwent ablation targetting any isoproterenol induced AF triggers, atrial substrate or inducible atrial tachycardias or flutters. Patients with PVi compared to PVr were more likely to have a history of persistent AF (64% vs. 26%; p<0.0001), obesity (BMI 30.4 vs. 28.2; p=0.05) and prior use of contact force sensing catheters (28% vs. 0.8%, p<0.0001). After a mean follow-up of 19±15 months, 56% of PVi patients remained in sinus rhythm compared to 76.3% of PVr patients (p=0.036). In a multivariable model, PVi patients and those with cardiomyopathy had a higher risk of recurrent atrial tachyarrhythmias (HR=3.6 95% CI 1.6-8.3, p=0.002 and HR=6.2, 95% CI 2.3-16.3, p<0.0001, respectively). In patients who have all pulmonary veins isolated at the time of the redo AF ablation, a strategy of targetting non-PV AF triggers and inducible flutters can still lead to AF freedom in more then half of patients. Patients with PVr, however, have a better long-term outcome. This article is protected by copyright. All rights reserved.