Progression of Atrial Fibrillation After a Failed Initial Ablation Procedure in Patients With Paroxysmal Atrial Fibrillation: A Randomized Comparison of Drug Therapy vs. Re-Ablation

Study Questions:

Is re-ablation superior to antiarrhythmic drug therapy (AADT) in patients with recurrent atrial fibrillation (AF) after a prior ablation procedure?

Methods:

One hundred fifty-four patients (mean age 56 years) with paroxysmal AF despite pulmonary vein isolation were randomly assigned to re-do ablation (n = 77) or AADT (n = 77) with propafenone, flecainide, or sotalol. Rhythm assessment during 3 years of follow-up was performed with an implantable loop recorder (ILR). The ILR data were collected every 3 months. Freedom from AF was defined as an AF burden ≤0.5%. The primary endpoint was progression of the AF burden or development of persistent AF.

Results:

During follow-up, the AF burden increased from baseline significantly more often in the AADT group (79%) than in the re-ablation group (25%). The mean AF burden at 36 months was significantly higher in the AADT group (18.8%) than in the re-ablation group (5.6%). Progression to persistent AF also occurred significantly more often in the AADT group (23%) than in the re-ablation group (4%). Only 12% of the AADT patients were AF-free during follow-up, whereas 58% of the re-ablation patients were AF-free off AADT.

Conclusions:

The authors concluded that re-do ablation is more effective than AADT in preventing AF progression in patients with paroxysmal AF who have failed to respond to an initial ablation procedure.

Perspective:

The two major strengths of this study are the randomization of patients to the two treatment arms and the use of ILRs to quantitate AF burden during follow-up. The study convincingly demonstrates the superiority of re-do ablation over AADT in patients with paroxysmal AF and a failed first ablation procedure.

Clinical Topics: Arrhythmias and Clinical EP, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Follow-Up Studies, Pulmonary Veins, Catheter Ablation, Disease Progression, Ovarian Follicle


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