Strategies for Recurrent Atrial Fibrillation in Patients Despite Durable Pulmonary Vein Isolation
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Ablation Procedure
2.3. Statistical Analysis
3. Results
3.1. Patient Characteristics
3.2. Ablation Strategies and Procedural Data
3.3. Safety
3.4. Follow-Up
4. Discussion
Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Abbreviations
AAD | Anti-arrhythmic drug |
AI | Artificial intelligence |
ACT | Activated clotting time |
AF | Atrial fibrillation |
AT | Atrial tachycardia |
BMI | Body mass index |
CA | Catheter ablation |
CFAE | Complex fractionated atrial electrograms |
CS | Coronary sinus |
CTI | Cavo-tricuspid isthmus |
DOAC | Direct oral anticoagulant |
ECG | Electrocardiogram |
EGM | Electrogram |
EHRA | European heart rhythm association |
GFR | Glomerular filtration rate |
HD | High density |
INR | International normalized ratio |
LA | Left atrium |
LAA | Left atrial appendage |
LVEF | Left ventricular ejection fraction |
MRI | Magnet resonance imaging |
PAF | Paroxysmal atrial fibrillation |
persAF | Persistent atrial fibrillation |
PV | Pulmonary vein |
PVI | Pulmonary vein isolation |
RA | Right atrium |
RFA | Radio frequency ablation |
TIA | Transitory ischemic attack |
TOE | Transoesophageal echocardiogram |
TTE | Transthoracic echocardiogram |
UFH | Unfractionated heparin |
Appendix A
Ablation Strategy | |||
---|---|---|---|
Linear | Substrate Modification | Combined | |
Number of patients | 38/89 (42.7%) | 15/89 (16.9%) | 36/89 (40.4%) |
Linear ablation strategies | |||
LA Isthmus | 2/38 (5.3%) | 2/36 (5.6%) | |
LA Roof | 9/38 (23.7%) | 14/36 (38.9%) | |
Inferior Line | 0/38 (0%) | 3/36 (8.3%) | |
Anterior line | 14/38 (36.8%) | 22/36 (61.1%) | |
Box | 27/38 (71.1%) | 14/36 (38.9%) | |
LAA | 0/38 (0%) | 1/36 (27.8%) | |
Non-linear ablation strategies | |||
CFAE | 10/15 (66.7%) | 22/36 (61.1%) | |
Ablation of low-voltage areas | 5/15 (33.3%) | 14/36 (38.9% | |
Ectopic foci | 1/15 (6.7%) | 2/36 (5.6%) |
Ablation Strategy | |||
Linear | Substrate Modification | Combined | |
Number of patients | 17/30 (56.6%) | 6/30 (20.0%) | 7/30 (23.3%) |
Linear ablation strategies | |||
LA Isthmus | 1/17 (5.9%) | 0/7 (4.7%) | |
LA Roof | 7/17 (41.2%) | 3/7 (42.8%) | |
Inferior Line | 0/17 (0%) | 1/7 (14.3%) | |
Anterior line | 1/17 (5.9%) | 3/7 (42.8%) | |
Box | 10/17 (58.8%) | 2/7 (28.6%) | |
LAA | 0/17 (0%) | 0/7 (20%) | |
Non-linear ablation strategies | |||
CFAE | 5/6 (83.3%) | 4/7 (57.1%) | |
Ablation of low-voltage areas | 1/6 (16.7%) | 3/7 (42.9% | |
Ectopic foci | 0/6 (0%) | 0/7 (0%) |
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Total | Ablation Strategy | p-Value | |||
---|---|---|---|---|---|
Linear | Non-Linear | Combined | |||
Sex (male) | 71/119 (59.7%) | 31/55 (56.3%) | 12/21 (57.1%) | 28/43 (65.1%) | 0.7 |
Age | 68.6 ± 9.5 | 67.1 ± 9.6 | 69.4 ± 10.7 | 70.1 ± 8.8 | 0.2 |
BMI (kg/m2) | 27.5 ± 4.6 | 27.4 ± 4.5 | 27.3 ± 4.2 | 27.6 ± 5.0 | 0.9 |
LVEF | |||||
LVEF ≥ 50% | 98/119 (82.4%) | 48/55 (87.3%) | 16/21 (76.2%) | 34/43 (79.1%) | 0.049 |
LVEF 40% to ≤50% | 13/119 (10.9%) | 4/55 (7.3%) | 3/21 (14.3%) | 6/43 (14.0%) | 0.5 |
LVEF 30% to ≤40% | 6/119 (5.0%) | 2/55 (3.6%) | 2/21 (9.5%) | 2/43 (4.6%) | 0.5 |
LVEF < 30% | 2/119 (1.7%) | 1/55 (1.8%) | 0/21 (0%) | 1/43 (2.3%) | 1.0 |
PersAF | 89/119 (74.8%) | 38/55 (69.1%) | 15/21 (71.4%) | 36/43 (83.7%) | 0.2 |
EHRA | |||||
1 | 1/119 (0.8%) | 0/55 (0%) | 0/21 (0%) | 1/43 (2.3%) | 0.5 |
2a | 7/119 (5.9%) | 3/55 (5.5%) | 2/21 (9.5%) | 2/43 (4.7%) | 0.8 |
2b | 44/119 (37.0%) | 23/55 (41.8%) | 3/21 (14.3%) | 18/43 (41.9%) | 0.1 |
3 | 64/119 (53.8%) | 28/55 (50.9%) | 14/21 (66.7%) | 22/43 (51.2%) | 0.4 |
4 | 3/119 (2.5%) | 1/55 (1.8%) | 2/21 (9.5%) | 0/43 (0%) | 0.1 |
LA-diameter (mm) | 42.2 ± 5.9 | 41.4 ± 6.2 | 42.2 ± 4.4 | 43.3 ± 6.1 | 0.3 |
Prior AF procedures | 1.6 ± 0.8 | 1.6 ± 0.8 | 1.9 ± 1.0 | 1.5 ± 0.7 | 0.5 |
Arterial hypertension | 90/119 (75.6%) | 39/55 (70.9%) | 17/21 (81.0%) | 34/43 (79.1%) | 0.7 |
Diabetes | 17/119 (14.3%) | 8/55 (14.5%) | 4/21 (19.0%) | 5/43 (11.6%) | 0.7 |
Hyperlipoproteinemia | 45/119 (37.8%) | 23/55 (41.8%) | 9/21 (42.9%) | 13/43 (30.2%) | 0.4 |
Coronary artery disease | 21/119 (17.6%) | 4/55 (7.3%) | 5/21 (23.8%) | 12/43 (27.9%) | 0.02 |
Aktive Smoking | 5/119 (4.2%) | 4/55 (7.3%) | 0/21 (0%) | 1/43 (2.3%) | 0.5 |
History of Smoking | 22/119 (18.5%) | 8/55 (14.5%) | 4/21 (19.0%) | 10/43 (23.3%) | 0.6 |
History of stroke or TIA | 9/119 (7.6%) | 5/55 (9.0%) | 0/21 (0%) | 4/43 (9.3%) | 0.4 |
GFR (mL/min; CKD-EPI) | 70.2 ± 19.4 | 71.7 ± 18.3 | 70.2 ± 23.8 | 68.3 ± 18.7 | 0.5 |
CHA2DS2-VASc-Score | 2.8 ± 1.5 | 2.5 ± 1.5 | 2.9 ± 1.4 | 3.1 ± 1.3 | 0.1 |
Medication | |||||
Beta-blockers | 100/119 (84.0%) | 47/55 (85.5%) | 17/21 (81.0%) | 36/43 (83.7%) | 0.9 |
AADs | 36/119 (30.3%) | 15/55 (27.3%) | 9/21 (42.9%) | 12/43 (27.9%) | 0.4 |
Anticoagulation | 111/119 (93.3%) | 49/55 (89.1%) | 20/21 (95.2%) | 42/43 (97.7%) | 0.3 |
Ablation Strategy | |||
---|---|---|---|
Linear | Substrate Modification | Combined | |
Linear ablation strategies | |||
LA Isthmus | 3/55 (5.5%) | 2/43 (4.7%) | |
LA Roof | 16/55 (29.1%) | 17/43 (39.5%) | |
Inferior Line | 0/55 (0%) | 4/43 (9.3%) | |
Anterior line | 15/55 (27.3%) | 25/43 (58.1%) | |
Box | 37/55 (67.3%) | 16/43 (37.2%) | |
LAA | 0/55 (0.0%) | 1/43 (2.3%) | |
Non-linear ablation strategies | |||
CFAE | 15/21 (71.4%) | 26/43 (60.5%) | |
Ablation of low-voltage areas | 6/21 (28.6%) | 17/43 (39.5% | |
Ectopic foci | 1/21 (4.8%) | 2/43 (4.7%) |
Total | Ablation Strategy | p-Value | |||
---|---|---|---|---|---|
Linear | Substrate Modification | Combined | |||
LA-scar | 72/119 (60.5%) | 27/55 (49.1%) | 12/21 (57.1%) | 33/43 (76.7%) | 0.0180 |
Procedure time (min) | 155.7 ± 60.0 | 144.1 ± 65.2 | 175.0 ± 55.4 | 161.3 ± 52.8 | 0.0176 |
Fluoroscopy dose (mGy/cm2) | 6084.8 ± 1412.3 | 4228.0 ± 4255.3 | 6724.3 ± 10494.8 | 8147.6 ± 8340.1 | 0.2 |
Fluoroscopy time (min) | 13.0 ± 10.4 | 9.8 ± 8.4 | 17.9 ± 11.5 | 14.7 ± 11.0 | 0.0024 |
RFA impulses | 76.3 ± 54.6 | 64.9 ± 30.5 | 69.2 ± 37.1 | 94.3 ± 77.1 | 0.2 |
RFA duration (s) | 2352.0 ± 1521.3 | 1981.5 ± 1412.6 | 3174.3 ± 1636.2 | 2443.5 ± 1469.8 | 0.0017 |
Total energy (J) | 82,043.2 ± 47,954.6 | 68,239.6 ± 41,766.8 | 98,242.7 ± 54,144.8 | 92,164.5 ± 48,556.0 | 0.0033 |
Total | Ablation Strategy | p-Value | |||
---|---|---|---|---|---|
Linear | Substrate Modification | Combined | |||
Stroke/TIA | - | - | - | - | - |
Pericardial effusion without tamponade | 2/119 (1.7%) | 2/55 (3.6%) | 1/21 (4.8%) | - | 0.4 |
Pericardial tamponade | - | - | - | - | - |
Severe groin hematoma requiring further intervention | - | - | - | - | - |
Aneurysma spurium | 2/119 (1.7%) | 1/55 (1.8%) | - | 1/43 (2.3%) | 0.5 |
AV-fistula | 1/119 (0.8%) | - | - | 1/43 (2.3%) | 0.5 |
Aspiration | 1/119 (0.8%) | - | - | 1/43 (2.3%) | 0.5 |
Sinus arrest | 1/119 (0.8%) | - | - | 1/43 (2.3%) | 0.5 |
Esophagoatrial fistula | - | - | - | - | - |
Phrenic nerve palsy | - | - | - | - | - |
Total | 7/119 (5.9%) | 3/55 (5.4%) | 1/21 (4.8%) | 4/43 (9.3%) | 0.9 |
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Ackmann, J.; Wörmann, J.; Lüker, J.; Pavel, F.; Scheurlen, C.; Maximidou, T.; van den Bruck, J.-H.; Schipper, J.-H.; Steven, D.; Sultan, A. Strategies for Recurrent Atrial Fibrillation in Patients Despite Durable Pulmonary Vein Isolation. J. Clin. Med. 2025, 14, 2250. https://doi.org/10.3390/jcm14072250
Ackmann J, Wörmann J, Lüker J, Pavel F, Scheurlen C, Maximidou T, van den Bruck J-H, Schipper J-H, Steven D, Sultan A. Strategies for Recurrent Atrial Fibrillation in Patients Despite Durable Pulmonary Vein Isolation. Journal of Clinical Medicine. 2025; 14(7):2250. https://doi.org/10.3390/jcm14072250
Chicago/Turabian StyleAckmann, Jana, Jonas Wörmann, Jakob Lüker, Friederike Pavel, Cornelia Scheurlen, Theodoros Maximidou, Jan-Hendrik van den Bruck, Jan-Hendrik Schipper, Daniel Steven, and Arian Sultan. 2025. "Strategies for Recurrent Atrial Fibrillation in Patients Despite Durable Pulmonary Vein Isolation" Journal of Clinical Medicine 14, no. 7: 2250. https://doi.org/10.3390/jcm14072250
APA StyleAckmann, J., Wörmann, J., Lüker, J., Pavel, F., Scheurlen, C., Maximidou, T., van den Bruck, J.-H., Schipper, J.-H., Steven, D., & Sultan, A. (2025). Strategies for Recurrent Atrial Fibrillation in Patients Despite Durable Pulmonary Vein Isolation. Journal of Clinical Medicine, 14(7), 2250. https://doi.org/10.3390/jcm14072250