Elsevier

Heart Rhythm

Volume 5, Issue 5, May 2008, Pages 679-685
Heart Rhythm

Original-clinical
Clinical predictors and relationship between early and late atrial tachyarrhythmias after pulmonary vein antrum isolation

https://doi.org/10.1016/j.hrthm.2008.01.031Get rights and content

Background

Several studies have reported early (EAT) and late (LAT) atrial tachyarrhythmias following atrial fibrillation (AF) ablation, but the factors associated with them and their clinical significance are not well known.

Objective

The purpose of this study was to investigate the predictors and the relationship between EAT and LAT after AF ablation.

Methods

A total of 1298 patients with paroxysmal (54%), persistent (18%), or permanent (28%) AF underwent intracardiac echocardiography-guided pulmonary vein antrum isolation and were followed for 41 ± 10 months. EAT and LAT were defined as an episode of AF or atrial flutter/tachycardia lasting longer than 1 minute that occurred within the first 3 months of ablation and after 3 months postablation, respectively.

Results

After a single ablation procedure, EAT developed in 514 (40%) patients and LAT in 292 (22%) patients. At a multivariable analysis, longer AF duration (odds ratio [OR] 1.03), history of hypertension (OR 1.32), left atrial enlargement (OR 1.55), permanent AF (OR 1.72), and lack of superior vena cava isolation (OR 1.60) were significantly associated with EAT. Independent predictors of LAT were longer AF duration (OR 1.03), history of hypertension (OR 1.65), persistent (OR 2.17) or permanent AF (OR 2.28), and occurrence of EAT (OR 30.62). The risk of LAT was inversely related to the time to first EAT occurrence (OR 20, 54, and 1,052 in first, second, and third month, respectively). Notably, 49% of patients with EAT did not experience LAT.

Conclusion

EAT strongly predict LAT. However, EAT did not automatically mean ablation failure. Delaying redo procedure may be appropriate during the first 2 months after ablation. Longer AF duration, hypertension, and nonparoxysmal AF are independent predictors of EAT and LAT.

Introduction

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with a prevalence between 0.9% and 2.5% in the general population and an increasing incidence with age.1, 2 The clinical significance and financial impact of AF management create a need for effective treatment. Antiarrhythmic drugs for prevention of AF recurrences frequently are ineffective and often are associated with adverse and toxic effects that may nullify the possible benefit of sinus rhythm maintenance. In the last 10 years, left atrial catheter ablation aimed at pulmonary vein (PV) isolation and/or elimination of the arrhythmic substrate has been proposed as a definitive cure for this arrhythmia.3 Some investigators have examined the incidence of AF after ablation and found that early arrhythmic recurrences (i.e., within the first 2 weeks to 3 months after the procedure) are common, occurring in as many as 50% of patients.4, 5, 6, 7, 8, 9 However, these recurrences often disappear after the initial period and do not necessarily indicate failure of the procedure over time. It is important to realize that these data derive from small series of patients with relatively short-term follow-up. Furthermore, the factors predictive of both early (EAT) and late atrial tachyarrhythmias (LAT) and their clinical relevance have not been thoroughly investigated.

The aim of the present study was to identify the clinical variables associated with EAT and LAT and to assess the relationship between these arrhythmias in a very large cohort of patients undergoing PV antrum isolation.

Section snippets

Patient population

Consecutive patients referred to Cleveland Clinic Foundation, Cleveland, Ohio, USA, or Umberto I Hospital, Mestre-Venice, Italy, for treatment of AF by PV antrum isolation between September 2001 and June 2005 were included in the study. On referral, all patient data were prospectively recorded in a computerized database.

All patients selected for PV antrum isolation had a history of symptomatic, drug-resistant paroxysmal, persistent, or permanent AF. Before the ablation procedure, all patients

Patient characteristics

The study enrolled 1,298 patients (1,088 at Cleveland Clinic Foundation and 210 at Umberto I Hospital). The baseline characteristics of these patients are summarized in Table 1. AF was paroxysmal in 699 (54%) patients, persistent in 230 (18%), and permanent in 369 (28%). Hypertension was present in 33% of cases and structural heart disease in 32% of cases. Left atrial diameter was >4 cm in 891 (69%) patients. Mean left ventricular ejection fraction was <40% in 115 (9%) patients.

PV antrum isolation

All four PV

Incidence, predictors, and clinical implications of EAT

Previous studies have examined the incidence of EAT, defined as the recurrence of AF or the development of new-onset left atrial flutter/tachycardia occurring within 2 weeks to 3 months after ablation.4, 5, 6, 7, 8, 9 According to these studies, the incidence of EAT ranges between 35% and 46%.4, 5, 6, 7, 8, 9 In the present study, we found a similar percentage (40%). EAT in our patients occurred more frequently within the first month after ablation, and the incidence progressively decreased

Study limitations

All patients were treated by the same ablation technique; therefore, we cannot exclude the possibility that using different techniques might yield different results. Nevertheless, the data reported in the literature seem to indicate that the ablation technique used does not influence the incidence of EAT, which is reported to be similar among the focal (39%),6 segmental (35%–41%),4, 6, 8 circumferential (46%),7 and antral (40%) approaches. However, considering the differences in long-term

Conclusion

The results of this study confirm that EAT are very frequent and demonstrate that such arrhythmias have an unfavorable prognostic significance in that they are strong predictors of LAT. This is especially true for EAT that occur in the second and third months after ablation. However, because nearly half of patients with EAT will not develop LAT, a conservative strategy is warranted during the first months postablation. Both EAT and LAT are significantly associated with longer duration of AF,

Acknowledgments

We thank Ms. Michelle Williams-Andrews, Dr. Mohamed Kanj, from the Cleveland Clinic Foundation, Dr. Andrea Corrado, and Dr. Michela Madalosso from Umberto I Hospital for contributions in data collection. We also thank Dr. Jennifer E. Cummings and Dr. Mauricio Arruda from the Cleveland Clinic Foundation for reading the manuscript and making several helpful suggestions.

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