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Brahier MS, Friedman DJ, Bahnson TD, Piccini JP. Repeat catheter ablation for atrial fibrillation. Heart Rhythm 2024; 21:471-483. [PMID: 38101500 DOI: 10.1016/j.hrthm.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/28/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023]
Abstract
Catheter ablation of atrial fibrillation (AF) is an established therapy that reduces AF burden, improves quality of life, and reduces the risks of cardiovascular outcomes. Although there are clear guidelines for the application of de novo catheter ablation, there is less evidence to guide recommendations for repeat catheter ablation in patients who experience recurrent AF. In this review, we examine the rationale for repeat ablation, mechanisms of recurrence, patient selection, optimal timing, and procedural strategies. We discuss additional important considerations, including treatment of comorbidities and risk factors, risk of complications, and effectiveness. Mechanisms of recurrent AF are often due to non-pulmonary vein (non-PV) triggers; however, there is insufficient evidence supporting the routine use of empiric lesion sets during repeat ablation. The emergence of pulsed field ablation may alter the safety and effectiveness of de novo and repeat ablation. Extrapolation of data from randomized trials of de novo ablation does not optimally inform efficacy in cases of redo ablation. Additional large, randomized controlled trials are needed to address important clinical questions regarding procedural strategies and timing of repeat ablation.
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Affiliation(s)
- Mark S Brahier
- Electrophysiology Section, Duke Heart Center, Duke University Hospital & Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel J Friedman
- Electrophysiology Section, Duke Heart Center, Duke University Hospital & Duke Clinical Research Institute, Durham, North Carolina
| | - Tristram D Bahnson
- Electrophysiology Section, Duke Heart Center, Duke University Hospital & Duke Clinical Research Institute, Durham, North Carolina
| | - Jonathan P Piccini
- Electrophysiology Section, Duke Heart Center, Duke University Hospital & Duke Clinical Research Institute, Durham, North Carolina.
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Kahle AK, Alken FA, Scherschel K, Meyer C. Prognostic implications of baseline rhythm during catheter ablation for atrial tachycardia. Clin Res Cardiol 2023:10.1007/s00392-023-02292-3. [PMID: 37710016 DOI: 10.1007/s00392-023-02292-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/21/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Atrial tachycardias (AT) occurring in patients after previous atrial fibrillation (AF) ablation are increasingly observed in clinical practice. Catheter ablation is the treatment of choice but an optimal workflow to improve patient outcome has not been defined. The purpose of this study was to assess procedural and clinical outcome depending on baseline rhythm at the beginning of AT ablation. METHODS A total of 380 patients (69 (61-75) years, 56.6% male) who underwent catheter ablation for consecutive AT after previous AF ablation were studied. RESULTS At the beginning of the procedure, 140 patients (36.8%) presented in sinus rhythm (SR), 208 (54.7%) with AT and 32 (8.4%) with AF. Patients in SR or with AT underwent shorter procedures (173 (132-213) minutes vs. 161 (120-203) minutes vs. 226 (154-249) minutes; p = 0.002) with more frequent termination to SR (87.9% vs. 81.3% vs. 56.3%; p < 0.001) than patients with AF. Acute procedural success did not differ between patients in SR or with AT but was higher compared to those with AF (96.4% vs. 97.1% vs. 87.5%; p = 0.033). During a follow-up of 290 (181-680) days, patients in baseline SR experienced arrhythmia recurrences less often (36.4% vs. 49.5% vs. 68.8%; p = 0.002) than patients with AT or AF. CONCLUSION Baseline rhythm during AT ablation predicts procedural and clinical outcome. Whereas acute procedural success does not differ between patients in SR or with AT, patients presenting in SR have a more favorable mid-term success rate.
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Affiliation(s)
- Ann-Kathrin Kahle
- Division of Cardiology, Angiology, Intensive Care Medicine, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Fares-Alexander Alken
- Division of Cardiology, Angiology, Intensive Care Medicine, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
| | - Katharina Scherschel
- Division of Cardiology, Angiology, Intensive Care Medicine, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Christian Meyer
- Division of Cardiology, Angiology, Intensive Care Medicine, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany.
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany.
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Wang Z, Lai Y, Wang Y, Wang J, Jiang C, He L, Guo X, Li S, Wang W, Jiang C, Liu N, Tang R, Long D, Sang C, Du X, Dong J, Ma C. Very-early symptomatic recurrence is associated with late recurrence after radiofrequency ablation of atrial fibrillation. Europace 2023; 25:euad189. [PMID: 37417712 PMCID: PMC10337823 DOI: 10.1093/europace/euad189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/29/2023] [Indexed: 07/08/2023] Open
Abstract
AIMS After radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF), the effect of very-early (within 48 h) symptomatic recurrence (VESR) on late (after 3 months of RFCA) recurrence (LR) has been seldomly reported. We aimed to explore the relationship between VESR and LR among post-RFCA patients. METHODS AND RESULTS This was a single-centre prospective cohort study that enrolled 6887 AF patients who received the first RFCA procedure from June 2018 to December 2021 at Beijing Anzhen Hospital. Patients were divided into four groups based on VESR and early (from 48 h to 3 months after RFCA) recurrence (ER): Group A (no VESR, no ER); Group B (VESR but no ER); Group C (ER but no VESR); and Group D (both VESR and ER). Three hundred and thirty (4.79%) patients experienced VESR (Groups B and D). With an average follow-up of 14.7 months after grouping, the Kaplan-Meier curve showed that LR risk in VESR patients was higher than in other patients (log-rank, P < 0.001), and the difference was significant in both paroxysmal (log-rank, P < 0.001) and persistent (log-rank, P < 0.001) AF patients (P for interaction = 0.118). In multivariate analysis, Groups B, C, and D were associated with a 2.161-, 5.409-, and 7.401-fold increase in the risk of LR, respectively. What is more, compared with Group A, VESR-atrial tachycardia and VESR-AF were related to a 3.467- and 5.564-fold LR risk, respectively. In VESR patients, classification based on ER and VESR modes improved the prediction potential of LR risk. CONCLUSION Very-early symptomatic recurrence is associated with an increased risk of LR.
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Affiliation(s)
- Zhen Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Yiwei Lai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Yufeng Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Jue Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Chao Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Liu He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Xueyan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Songnan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Wei Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Chenxi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Nian Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chao Yang District, Beijing 100029, China
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Havranek S, Fingrova Z, Skala T, Reichenbach A, Dusik M, Jansa P, Ambroz D, Dytrych V, Klimes D, Hutyra M, Kautzner J, Linhart A, Wichterle D. Catheter ablation of atrial fibrillation and atrial tachycardia in patients with pulmonary hypertension: a randomized study. Europace 2023:7161651. [PMID: 37178136 DOI: 10.1093/europace/euad131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/14/2023] [Indexed: 05/15/2023] Open
Abstract
AIMS Atrial fibrillation (AF), typical atrial flutter (AFL), and other atrial tachycardias (ATs) are common in patients with pulmonary hypertension. Frequently, several supraventricular arrhythmias are successively observed in individual patients. We investigated the hypothesis of whether more extensive radiofrequency catheter ablation of the bi-atrial arrhythmogenic substrate instead of clinical arrhythmia ablation alone results in superior clinical outcomes in patients with pulmonary arterial hypertension (PH) and supraventricular arrhythmias. METHODS AND RESULTS Patients with combined post- and pre-capillary or isolated pre-capillary PH and supraventricular arrhythmia indicated to catheter ablation were enrolled in three centres and randomized 1:1 into two parallel treatment arms. Patients underwent either clinical arrhythmia ablation only (Limited ablation group) or clinical arrhythmia plus substrate-based ablation (Extended ablation group). The primary endpoint was arrhythmia recurrence >30 s without antiarrhythmic drugs after the 3-month blanking period. A total of 77 patients (mean age 67 ± 10 years; 41 males) were enrolled. The presumable clinical arrhythmia was AF in 38 and AT in 36 patients, including typical AFL in 23 patients. During the median follow-up period of 13 (interquartile range: 12; 19) months, the primary endpoint occurred in 15 patients (42%) vs. 17 patients (45%) in the Extended vs. Limited ablation group (hazard ratio: 0.97, 95% confidence interval: 0.49-2.0). There was no excess of procedural complications and clinical follow-up events including an all-cause death in the Extended ablation group. CONCLUSION Extensive ablation, compared with a limited approach, was not beneficial in terms of arrhythmia recurrence in patients with AF/AT and PH. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov; NCT04053361.
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Affiliation(s)
- Stepan Havranek
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Zdenka Fingrova
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Tomas Skala
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Adrian Reichenbach
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Milan Dusik
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Pavel Jansa
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - David Ambroz
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Vladimir Dytrych
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Dalibor Klimes
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Martin Hutyra
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Josef Kautzner
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ales Linhart
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Dan Wichterle
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
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