SHANGHAI, CHINA. It is becoming increasingly clear that as many as 30 to 50% of afibbers undergoing a radiofrequency catheter ablation will need a repeat procedure. What is not clear is the optimal timing of the second procedure. Should it be performed as soon as possible after the initial procedure, or should there be a wait time to see if the post-procedure arrhythmias will settle down on their own? A group of electrophysiologists from Shanghai Chest Hospital now suggest that having the repeat ablation approximately 1 month after the initial procedure is optimum.
Their trial involved 375 patients with paroxysmal atrial fibrillation (PAF) who were treated at the hospital during the period July 2008 to February 2009. The average age of the patients was 53 years, 62% were male, and all had been unsuccessfully treated with at least one antiarrhythmic drug during the 6 months preceding their first circumferential pulmonary vein isolation (CPVI) procedure. All patients were discharged after 1 week in hospital and then underwent frequent electrocardiography and Holter monitoring for the 21-month trial duration.
A total of 117 (31.2%) of ablatees experienced early recurrences of atrial tachyarrhythmia (AF, atrial flutter, atrial tachycardia lasting longer than 30 seconds) during the first 2 weeks following their initial procedure. They were randomized into two groups – an early re-ablation group (ERA) with 57 patients, and a later re-ablation group (LRA) with 60 patients. Recurrences occurred an average of 6.7 days (2 to 22 days) from the initial ablation in the ERA group. They had gradually subsided within one month in 17 patients leaving 40 who underwent a repeat ablation approximately 28 days (24 to 42 days) after their first procedure. Pulmonary vein reconnection was observed in 36 (80%) of the 40 patients and the gaps were re-ablated and focal and linear ablation performed as necessary. At the end of the 6.5-month follow-up from the second procedure, 47 patients (82.5%) in the ERA group were free of arrhythmias, with 5 (10.6%) achieving this status with the aid of previously ineffective antiarrhythmics.
In the LRA group recurrences occurred an average of 8.2 days (1 to 29 days) from the initial ablation. They had gradually subsided within one month in 20 patients, leaving 40 who underwent a repeat ablation approximately 98 days (90 to 122 days) after their first procedure. Pulmonary vein reconnection was observed in 29 (72.5%) of the 40 patients and the gaps were re-ablated and focal and linear ablation performed as necessary. At the end of the 15.2-month follow-up from the second procedure, 51 patients (85%) in the LRA group were free of arrhythmias with 6 (11.8%) achieving this status with the aid of previously ineffective antiarrhythmics. The Shanghai EPs conclude that there is no advantage in postponing a repeat ablation for patients whose early recurrences of atrial tachyarrhythmias do not subside within one month following their initial procedure. They suggest that doing the second procedure about a month following the first one would be optimum. They also point out that a reduction in the number of weekly AF episodes during the first month is a reliable indicator that episodes will have subsided by the end of the month.
Wang, X, Zhou, L, et al. Early recurrences after paroxysmal atrial fibrillation ablation: when is the proper timing for reablation? PACE, Vol. 34, June 2011, pp. 709-16
Editor's comment: Undergoing a follow-up ablation sooner rather than later, if post-procedure arrhythmias persist, would make sense, especially if the recurrences are frequent, long or severe. It is interesting to note that the complete success rate (no AF, no antiarrhythmics) was 74% for the ERA group and 75% for the LRA group. Corresponding numbers for partial success (no AF, but still on antiarrhythmics) were 8% and 10% respectively.