Repeat ablation strategies in atrial fibrillation patients with durably isolated pulmonary veins: insights from the Netherlands Heart Registration

Background and aims: In 15–40% of patients undergoing repeat ablation for AF recurrence, all pulmonary veins (PVs) are durably isolated. Currently, there is limited evidence on the appropriate treatment strategy for these patients. We aimed to characterize and compare the effectiveness of different re-ablation strategies. Methods: All patients referred for repeat AF ablation with all PVs durably isolated at 8 hospitals in the Netherlands were included [Netherlands-Heart-Registration (NHR); 2016–2019]. NHR data were were used to determine the presence of PV-reconnection, the ablation strategy used, and the outcome of ablation (atrial arrhythmia recurrence > 30 sec.). The effectiveness of ablation strategies was assessed with multivariable Cox models. Results: Of 2311 repeat AF ablations performed, 274 (11.9%) patients had all PVs durably isolated. Median age was 66 (IQR:58–70) years, 44.2% women, 45.6% had persistent/long-standing-persistent AF. In 33 (12.0%) patients, no ablation was performed. A single ablation strategy was performed most often (41.2%). Posterior wall ablation (58.4%) was performed most often, followed by PV-antralization (26.3%). Over 2.0 (1.0–3.3) years, 147 (59.8%) patients had an atrial arrhythmia recurrence, and 30 (12.7%) patients had another repeat AF ablation within 1 year. After multivariable adjustment, no difference in atrial-arrhythmia recurrences was detected between individual ablation strategies, number of strategies performed, and type of atrial-arrhythmia (p > 0.05 for all). Left-atrial-volume-index was associated with a higher recurrence-risk [aHR 1.03(95%CI 1.01–1.05)]. Conclusion: In patients with durably isolated PVs, a high proportion experienced recurrence of atrial arrhythmias, with no difference in recurrence rates between different re-ablation strategies.