Incidence, Characteristics and Prognostic Significance of Early Recurrences Following Different Ablation Approaches for Persistent Atrial Fibrillation

Background: Early recurrence of atrial tachyarrhythmia (ERAT) is common following catheter ablation of atrial fibrillation (AF). The specific clinical and arrhythmia characteristics of ERAT influencing late recurrence risk in persistent AF is unclear. Additionally, the impact of different ablation strategies on the incidence and prognostic significance of ERAT remains unknown.

Objectives: This study aimed to assess the incidence, characteristics and prognostic impact of ERAT in patients with persistent AF undergoing pulmonary vein isolation (PVI) alone or PVI with posterior wall isolation (PWI) in CAPLA (Catheter Ablation for Persistent AF: A Multicenter Randomized Trial of PVI vs. PVI with PWI).

Methods: Trial participants monitored via implantable cardiac devices or twice-daily electrocardiogram transmissions were included. Atrial arrhythmia recurrences lasting >30 seconds were classified as ERAT (within 3 months post ablation) or late recurrence (between 3-12 months).

Results: Of the 282 included patients, ERAT occurred in 124 (44.0%). ERAT portended an increased incidence of late recurrence (68.5% vs. 32.9%; HR 3.36; 95% CI 2.35-4.79) and significantly higher post-blanking period AF burden (median 0.66%[IQR, 0-8.35%] vs. 0%[0-0.55%]). The HR for late recurrence was 2.34 (95% CI 1.48-3.71), 2.89 (95% CI, 1.63-5.12) and 6.00 (95% CI, 3.86-9.32) when latest ERAT occurred in the first, second and third month, respectively. Late recurrence risk was particularly elevated in patients with high-burden, frequent or symptomatic ERAT. Ablation strategy did not impact the incidence, burden, arrhythmia characteristics or prognostic significance of ERAT.

Conclusion: ERAT following radiofrequency ablation of persistent AF is an independent predictor of late recurrence and increased post-blanking period AF burden. An individualised assessment of early recurrences is warranted to critically evaluate their clinical significance.