Pulmonary vein antral isolation for paroxysmal atrial fibrillation: results from long-term follow-up.

Introduction: Pulmonary veins play an important role in triggering atrial fibrillation (AF). Pulmonary vein isolation (PVI) is an effective treatment for patients with paroxysmal AF. However, the late AF recurrence rate in long-term follow-up of circumferential PV antral isolation (PVAI) is not well documented. We sought to determine the time to recurrence of arrhythmia after PVAI, and long-term rates of sinus rhythm after circumferential PVAI.

Methods: One hundred consecutive patients with a mean age of 54 ± 10 years, with paroxysmal AF who underwent PVAI procedure were analyzed. Isolation of pulmonary veins was based on an electrophysiological and anatomical approach, with a nonfluoroscopic navigation mapping system to guide antral PVI. Ablation endpoint was vein isolation confirmed with a circular mapping catheter at first and subsequent procedures. Clinical, ECG, and Holter follow-up was undertaken every 3 months in the first year postablation, every 6 months thereafter, with additional prolonged monitoring if symptoms were reported. Time to arrhythmia recurrence, and representing arrhythmias, were documented.

Results: Isolation of all 4 veins was successful in 97% patients with 3.9 ± 0.3 veins isolated/patient. Follow-up after the last RF procedure was at a mean of 39 ± 10 months (range 21-66 months). After a single procedure, sinus rhythm was maintained at long-term follow-up in 49% patients without use of antiarrhythmic drugs (AADs). After repeat procedure, sinus rhythm was maintained in 57% patients without the use of AADs, and in 82% patients including patients with AADs. A total of 18 of 100 patients had 2 procedures and 4 of 100 patients had 3 procedures for recurrent AF/AT. Most (86%) AF/AT recurrences occurred ≤ 1 year after the first procedure. Mean time to recurrence was 6 ± 10 months. Kaplan-Meier analysis on antiarrhythmics showed AF free rate of 87% at 1 year and 80% at 4 years. There were no major complications.

Conclusion: PVAI is an effective strategy for the prevention of AF in the majority of patients with PAF. Maintenance of SR requires repeat procedure or continuation of AADs in a significant proportion of patients. After maintenance of sinus rhythm 1-year post-PVAI, a minority of patients will subsequently develop late recurrence of AF.