title: Fast atrial activity predicts recurrence of atrial fibrillation after pulmonary vein isolation: results from a prospective randomized study.
abstract: BACKGROUND
  Recurrence of atrial fibrillation (AF) after ablative treatment is common. We hypothesized that AF recurrence is heralded by fast ectopic atrial activity occurring after electrical reconnection of previously isolated pulmonary veins.
  
  
  METHODS
  Patients with paroxysmal or persistent AF undergoing pulmonary vein isolation (PVI) were followed up by 24-h Holter monitoring every 3 months for the first year and every 6 months thereafter. Antiarrhythmic drugs were withdrawn after a blanking period of 4 weeks for paroxysmal and 3 months for persistent AF. Ectopic atrial activity was defined as a burden of atrial extrasystoles >5% of the total QRS number. Fast atrial activity was present if mean cycle length of ectopic atrial activity was shorter than 50% of the mean cycle length of sinus rhythm in the last ten heartbeats. Patients with symptomatic fast atrial activity but without AF recurrence were randomized to undergo a second PVI procedure or resume antiarrhythmic medication. During follow-up, a 24-h Holter recording was performed every 3 months. Additionally, a 7-day external loop recording was performed in every pt with palpitations and no AF or ectopic atrial activity in the 24-h Holter.
  
  
  RESULTS
  One hundred twenty-four pts with AF (88 paroxysmal, 36 persistent) developed fast atrial activity 6 ± 3 months after PVI. Twenty-two pts were asymptomatic and eight pts refused randomization. Ninety-four pts (61 men, age 57 ± 12 years) were randomized to either receive a second PVI procedure (group I, 48 pts) or antiarrhythmic medication (group II, 46 pts). Re-PVI in group I was performed 10 ± 8 months after the first PVI. During a follow-up of 20 ± 6 months, 11 pts of group I (23%) and 43 pts of group II (93%) had recurrence of AF. The mean time of AF recurrence after appearance of fast atrial activity was 4 ± 2 in group I and 5 ± 3 months in group II.
  
  
  CONCLUSIONS
  In patients with atrial fibrillation and after the first PVI procedure, appearance of symptomatic fast atrial activity is associated with a high risk of AF recurrence. Re-isolation of reconnected pulmonary veins in these pts significantly reduces the risk of AF recurrence.
authors.affiliation: Department of Internal Medicine/Cardiology, German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany, kriatselis@gmx.de.
authors.forename: Charalampos
authors.initials: C
authors.lastname: Kriatselis
authors.forename: Jan
authors.initials: J
authors.lastname: Kaufmann
authors.forename: Sotirios
authors.initials: S
authors.lastname: Nedios
authors.forename: Jun
authors.initials: J
authors.lastname: Liu
authors.forename: Jin-Hong
authors.initials: JH
authors.lastname: Gerds-Li
authors.forename: Eckart
authors.initials: E
authors.lastname: Fleck
mesh_terms: D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects* / Q000379:methods; D004562:Electrocardiography / Q000379:methods*; D015716:Electrocardiography, Ambulatory / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000473:pathology / Q000601:surgery*; D012008:Recurrence; D012086:Reoperation / Q000379:methods; D018570:Risk Assessment; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D000889:Anti-Arrhythmia Agents