Recurrence of Atrial Arrhythmias Despite Persistent Pulmonary Vein Isolation After Catheter Ablation for Atrial Fibrillation: A Case Series

Objectives The aim of this study was to categorize arrhythmia mechanisms and to summarize ablation strategies in patients with persistent pulmonary vein isolation (PVI) at the time of redo procedures. Background Persistent PVI is more frequently seen in patients undergoing redo procedures for recurrent atrial arrhythmias after catheter ablation for atrial fibrillation (AF). Methods Consecutive patients who underwent their first AF ablation procedures at Brigham and Women's Hospital were screened and included if they had persistent isolation of all pulmonary veins at the time of redo procedures. Results Of 300 consecutive patients undergoing first AF ablation procedures, redo procedures were performed in 63 (21%), and 26 patients (9%) had persistent PVI. Of those, 11 had recurred with AF and 15 with organized atrial tachycardia (AT). During the index procedure, linear ablation was performed in 46% of patients with recurrent AF and 93% with recurrent organized AT (p = 0.020). At the time of last follow-up, 2 of 10 patients (20%) in the AF group and 10 of 15 patients (67%) in AT group were in sinus rhythm, without class I or III antiarrhythmic drugs (p = 0.022). Conclusions Patients with recurrence of atrial arrhythmia despite persistent PVI frequently present with organized AT. Linear ablation during the index procedure is associated with recurrence of organized AT. Recurrence rates after redo procedures were higher if patients had recurrent AF after the index procedure, and these patients often presented with AF again. Patients with recurrent AF despite persistent PVI may represent a population with lower success rates of catheter ablation.