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

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

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

4. 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

5. 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.

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

7. 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

8. Frequency of arrhythmias at time of repeat ablation
Reconnected PV >95%
PV trigger %
Development of new trigger %
Stable, regular arrhythmia other than afib %
La Flutter %
Ra Flutter %
Mainigi: JCEP 2007

9. 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

10. 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)

11. 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)

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

13. 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:

14. 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:
Copyright © American Heart Association

18. 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.

19. 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

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

23. Thank you