Long-Term Outcome Following Successful Pulmonary Vein Isolation: Pattern and Prediction of Very Late Recurrence

Arti N. Shah, MS, MD; Suneet Mittal, MD; Tina C. Sichrovsky, MD; Delia Cotiga, MD; Aysha Arshad, MD; Kataneh Maleki, MD; Walter J. Pierce, MD; Jonathan S. Steinberg, MD

Disclosures

J Cardiovasc Electrophysiol. 2008;19(7):661-667. 

In This Article

Abstract and Introduction

Abstract

Background: Despite encouraging results of pulmonary vein isolation (PVI) ablation for atrial fibrillation (AF), it is unclear whether there is genuine cure or there is an important attrition rate. We sought to determine the long-term outcome of the initial responders who experienced a prolonged AF-free complete response.
Methods: From a series of 350 consecutive patients who underwent PVI for AF, 264 patients (75%) (males 71%, age 57 ± 12 years, paroxysmal AF 87%) who demonstrated ≥1 year AF-free follow-up on no antiarrhythmic drugs were followed for 1-5 years.
Results: During 28 ± 12 months follow-up, 23 of 264 (8.7%) patients had recurrence of AF. The actuarial recurrence at 2 years postablation was 5.8% and increased to 25.5% at 5 years. Compared with long-term responders, more patients with late recurrence had hypertension (HR = 2.18, P = 0.009) and hyperlipidemia (HR = 4.01, P = 0.0005). Among 18 patients with recurrent AF necessitating repeat PVI, 15 (83%) required re-isolation of > 1 PV and 28 of 45 (58%) PVs showed reconnection. All PVs were re-isolated and five (28%) patients had additional linear ablation. All 15 patients became AF-free again.
Conclusions: Although most patients following PVI remain AF-free, some patients develop "late" recurrence of AF. The "late" recurrence patients are more likely to have hypertension and hyperlipidemia. Most late recurrences are associated with PV reconnections. Our observations emphasize the importance of continued long-term vigilance for AF recurrence, and also raise concerns regarding the need for long-term anticoagulation therapy.

Introduction

Catheter ablation is a remarkably effective intervention for a broad spectrum of chronic, recurrent, or refractory supraventricular and ventricular tachyarrhythmias. After a successful procedure and a suitable observation period, the absence of recurrent arrhythmia is considered synonymous with cure. Since its introduction into clinical practice,[1,2,3] ablation using a strategy of pulmonary vein isolation (PVI) has become an important treatment option in patients with atrial fibrillation (AF). Published studies suggest that approximately 33-86% of patients undergoing PVI would have an effective procedural outcome, with no AF observed and patients described as "cured."[4,5,6,7,8] These studies, however, have been limited by relatively small number of patients, varying ablation techniques, and relatively short follow-up durations of 1 week to 15 months.[2,3,9,10,11] Data regarding the long-term follow-up of patients with an initially favorable procedural response are sparse, but suggest that some patients may have a "very late" recurrence.[8,12,13,14] Because the mechanism of AF is complicated and variable, especially over time, involving the interaction of substrate and heterogeneous trigger sites, it is important to define the long-term durability of a desirable response to ablation for AF. The clinical implications when AF recurs are much more ominous than most other arrhythmias because of the potentially deleterious long-term consequences of AF, especially if unrecognized. Most importantly, there is a lack of consensus and guidelines as regard the use of chronic anticoagulation after successful ablation for AF, but it is very likely that many patients will no longer receive warfarin and be protected against the risk of stroke.[15]

Our cohort of patients who undergo AF ablation is enrolled in a long-term follow-up program, even if the procedure is fully successful. This report focuses on the patients who had a complete response to ablation, eliminating all AF and the need for antiarrhythmic therapy, for at least 1 year. The objectives of this study were to describe the attrition rate after initially successful results, and the risk factors, clinical complications, and possible mechanisms of very late recurrence.

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