title: Electrophysiologic findings and long-term outcomes in patients undergoing third or more catheter ablation procedures for atrial fibrillation.
abstract: BACKGROUND
  Pulmonary vein (PV) status, arrhythmia sources, and outcomes with ≥3 ablation procedures have not been characterized.
  
  
  RESULTS
  All patients with ≥3 procedures were included and underwent antral reisolation of reconnected PVs and ablation of non-PV triggers. Of 2,886 patients who underwent PVI, 181 (6%) had more than 2 ablation procedures (3 procedures in 146 and ≥4 procedures in 35). In 12 patients, the clinical arrhythmia was other than AF. Of the remaining 169 patients, 69 (41%) had 4 reconnected PVs, 27 (16%) had 3, 31 (18%) had 2, and 29 (17%) had 1. Only 13 (8%) had all PVs still isolated. Provocative techniques in 127 patients initiated PV triggers in 92 patients, including AF or PV atrial tachycardia in 64 (50%), and reproducible PV APDs in 28 (22%). Thirty-six (20%) had a new non-PV trigger targeted. At a mean of 36 months (12-119 months) after last procedure, 63 patients (47%) had no AF off antiarrhythmic drugs (AAD); 28 (21%) had no AF with AAD; and 18 (13%) had rare AF with good symptom control; 26 patients (19%) had recurrent AF.
  
  
  CONCLUSIONS
  At time of third or greater AF ablation, PV reconnection is the rule (92%) and PV triggers initiating AF can be demonstrated. Following repeat PVI and targeting non-PV triggers, 81% of patients had clinical AF control. Our findings suggest that PV reisolation and attempts to identify and eliminate non-PV triggers are effective and support the role of multiple repeat procedures for AF recurrence.
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: David
authors.initials: D
authors.lastname: Lin
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Santangeli
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Erica S
authors.initials: ES
authors.lastname: Zado
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Rupa
authors.initials: R
authors.lastname: Bala
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Mathew D
authors.initials: MD
authors.lastname: Hutchinson
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Riley
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: David S
authors.initials: DS
authors.lastname: Frankel
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Fermin
authors.initials: F
authors.lastname: Garcia
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Dixit
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Callans
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Francis E
authors.initials: FE
authors.lastname: Marchlinski
mesh_terms: D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects; D005260:Female; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015143:Philadelphia; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D012008:Recurrence; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000889:Anti-Arrhythmia Agents
keywords: atrial fibrillation; catheter ablation; pulmonary vein isolation; reconnection; repeat ablation