Circumferential pulmonary vein isolation: wait or stop early after initial successful pulmonary vein isolation?

Circumferential pulmonary vein isolation (PVI) is the current standard of interventional atrial fibrillation (Afib) therapy. However, recurrence rate of Afib varies considerably after ablation between different series and is mainly attributed to the recovery of pulmonary vein (PV) conduction after initial successful PVI.

Waiting longer during the initial PVI procedure and re-ablating any re-conduction may prolong procedure duration but should improve outcome with fewer relapses during follow-up.

Circumferential PVI with radiofrequency energy according to an electro-anatomical reconstruction of the left atrium and the PV ostia. A total of 107 consecutive patients who were presented to our hospital for circumferential PVI, were randomly assigned to prolongation of the waiting period (n= 54, 50.5%) or immediate termination of the procedure after initial successful isolation (n= 53, 49.5%). Ablation was started in an alternating manner at the lateral (n= 51, 47.7%) or septal veins (n= 56, 52.3%). Patients had paroxysmal (n= 70, 65.4%) and persistent Afib (n= 37, 34.6%). A total of 36 gaps occurred in 27 patients (50%) during 1 h after initial successful PVI. Without any blanking period 24 patients (44.4%) were free of any arrhythmia in the wait group and 23 patients (43.4%) in the stop group. Sixteen patients (29.6 and 30.2%) underwent re-ablation for symptomatic recurrences of atrial arrhythmias in each group. With re-ablation 45 patients (83.3%) were free of any arrhythmia in the wait group and 46 patients (86.8%) in the stop group. In addition there was no difference in the type of recurring arrhythmia in both groups.

The risk of early PV recovery was considerable. However, immediate re-ablation of early re-conduction did not result in a reduced recurrence rate of Afib during follow-up.