Redo afib ablation John R Onufer MD FHRS Best approach is to achieve complete durable pv isolation the first time

Why we fail at atrial fib ablations Repeated ablations 1. Lesions not permanent 2. More ablation targets 3. Mechanism ?

Primary Effectiveness Analysis Treatment Success 30 days CRYO 69.9% 114/163 Treatment success (%) P<0.001 DRUG Rx 7.3% 6/82 Blanked Days KM estimate 68.6% (SE 3.9%) vs 7.3% (SE 2.9%)

Five year single center results 1. One procedure, successful rate is low 2. Results could be better if all patients agreed to have multiple procedures

When does Recurrence Occur Early (<3 months) Marker of increased risk of long term failure However, 30-50% go on to be free of afib long term Late (3-12 months) More likely to represent Rx failure Early recurrence and multiple AF foci during original procedure strongest predictors of late recurrence. Very late (>12 months) Majority will have pv reconnection and have other non pulmonary sites ablated.

Surgical Maze procedure Freedom from symptomatic AF at 10 years was 85%. Circ Arrhythm Electrophysiol 2012;5;8-14

Recurrent Atrial arrhythmias after afib ablation PV reconnection Non-PV triggers Focal or re-entrant atrial tachycardias Aflutter Tv-ivc isthmus La mitral annulus La septal or roof

Frequency of arrhythmias at time of repeat ablation Reconnected PV >95% PV trigger 54-77% Development of new trigger 14-18% Stable, regular arrhythmia other than afib 18.7-50% La Flutter 6.7% Ra Flutter 6.7% Mainigi: JCEP 2007

Risk Factors for recurrence Type and duration of afib Proxysmal vs persistent Cardiac structural abnormalities LA size, LV function, HCM Characteristic of the atrial electrical substrate Clinical factors Htn, osa, increased BMI

PV recurrence Mechanism likely multifactorial Inadequate PV isolation Inadequate recognition and treatment of preexisting non pv substrate Under detection of earlier recurrences Interval disease progression despite sinus rhythm (atrial remodeling and fibrosis)

Redo Atrial fibrillation Ablation Stop-AF: proxysmal afib redo rate 20% Thermacool afib: Paroxysmal and persistent afib redo rate 12% TTOP: Long lasting persistent afib redo rate (not yet published)

Detecting and modifying PV reconnnection Waiting time Adenosine Steroids Atntiarrhythmic drugs Upstream therapy

Waiting time 75 pts with paf mean age 55 Double lasso, pv venography and /or 3D mapping The 4 PVs were individually targeted Waiting time 30, 60, 90 min Yamanee,et al. Circ AE 2011,4:601-608

The demonstration of the mean number of reconnection gaps at each provocation step (A, right superior and right inferior pulmonary vein [PV]; B, left superior and left inferior PV). The demonstration of the mean number of reconnection gaps at each provocation step (A, right superior and right inferior pulmonary vein [PV]; B, left superior and left inferior PV). As shown in A, the mean number of reconnected gaps was largest in time 1 and decreased according to the progression of provocative stage in the right superior PV (•), whereas no significant difference was observed among the provocative stages in the right inferior PV (○). B, Similar to the right veins, the mean number of reconnected gaps decreased according to the progression of provocative stage in the left superior PV (♦), whereas no significant difference was observed among the stages in the left inferior PV (◊). In both the right and left superior PVs, the number of reconnected gaps was significantly smaller at ATP 1, time 3, and ATP 3 compared with that of time 1 (*P<0.01). Yamane T et al. Circ Arrhythm Electrophysiol 2011;4:601-608 Copyright © American Heart Association

HRS concensus document 1. Ablation strategies that target the PVs and or the PV antrum are the cornerstone for most AF procedures If the PVs are targeted, electrical isolation should be the goal Achievement of electrical isolation requires, at a minimum, assessment and demonstration of entrance block into the PV. Monitoring for PV reconduction for 20 minutes following initial PV isolation should be considered.

Practical Approach to Redo Procedures PVs isolated yes no Isolate PVs SVC, CS, Ligament Of Marshal, Crista Terimalis, LA posterior wall Ablate non-PV triggers Ablate inducible atrial flutters Anatomical Non-PV Ablation

Implications Better characterization of of non PV baseline substrate Pt counseling and education Improved efforts to identify mechanism at time or reablation

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