Cause of very late recurrence of atrial fibrillation or flutter after catheter ablation for atrial fibrillation.

The major mechanism underlying the early recurrence of atrial fibrillation (AF) after ablation is mainly reconnection of the isolated pulmonary vein (PV); however, the mechanism responsible for very late recurrence (VLR) has not been fully elucidated. The purpose of the present study was to investigate the mechanism underlying VLR. The study population included 150 consecutive patients with AF who underwent a second session of catheter ablation because of recurrence. We divided them into 2 groups according to the point of initial AF recurrence: the late recurrence group (LR group, initial recurrence 3 to 12 months after ablation, n = 124) and the VLR group (initial recurrence >12 months after ablation, n = 26). We identified PVs with ectopic foci (trigger PVs) in the first procedure and checked their electrical reconnection in the second procedure. The prevalence of PV reconnection and trigger PV reconnection were significantly lower in the VLR group than in LR group (LR vs VLR, 90% vs 69% and 48% vs 27%, p = 0.007 and p = 0.045, respectively). In the VLR group, left ventricular systolic and diastolic function were significantly worse than in the LR group, and more patients in the VLR group required non-PV trigger ablation in the second session than did those in the LR group (30% vs 54%, p = 0.034). In conclusion, electrical PV reconnection contributed less to VLR than to LR. Progression of the AF substrate might be an important mechanism responsible for VLR.