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Routine Pulmonary Vein Re-Isolation
Study Questions:
Does routine early pulmonary vein (PV) re-isolation improve the outcomes of radiofrequency catheter ablation for paroxysmal atrial fibrillation (PAF)?
Methods:
Eighty patients (mean age 61.5 years) with PAF underwent PV isolation using a force-sensing ablation catheter in the PRESSURE (Pulmonary Vein Re-Isolation as a Routine Strategy: A Success Rate Evaluation) study. The patients were randomly assigned to standard care (SC, n = 40) or to a repeat procedure (RP, n = 40) 2 months later, regardless of symptoms, to re-isolate the PVs that had regained conduction. A repeat procedure after the 3-month blanking period was offered to patients in the SC group with recurrent AF. Surveillance for recurrent AF was performed on a daily basis and whenever symptomatic using a handheld monitor. Recurrence was defined as an atrial tachyarrhythmia (AT) after a 3-month blanking period. A quality-of-life questionnaire was administered at baseline and 6 and 12 months of follow-up.
Results:
In the RP group, 62.5% of patients were found to have ≥1 reconnected PV, all of which were successfully reconnected. In the SC group, 22.5% of patients underwent a second PV isolation procedure at a median follow-up of 7 months. AT recurrence at 12 months was significantly lower in the RP group (17.5%) than in the SC group (42.5%), and quality-of-life scores were significantly higher in the RP group.
Conclusions:
Routine early re-isolation of reconnected PVs improves the outcomes of PV isolation in patients with PAF.
Perspective:
This study provides strong evidence that early routine re-intervention after PV isolation for PAF improves outcomes after a 3-month blanking period. However, other studies have shown that PV reconnection can occur even in patients without recurrent AF. There are two reasons that the RP strategy is unlikely to be incorporated into clinical practice: 1) this strategy clearly is more expensive than SC, and 2) many patients will prefer to defer a redo procedure until it becomes clinically necessary.
Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Pulmonary Veins, Quality of Life, Tachycardia, Treatment Outcome
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