Silent pulmonary veins at redo ablation for atrial fibrillation: Implications and approaches

Background Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Despite promising success rates, redo ablation is sometimes required. At redo, PVs may be found to be isolated (silent) or reconnected. We studied patients with silent vs reconnected PVs at redo and analysed associations with adverse outcomes. Methods Patients undergoing redo AF ablations between 2013 and 2019 at our institution were included and stratified into silent PVs or reconnected PVs. The primary outcome was a composite of further redo ablation, non-AF ablation, atrioventricular nodal ablation, and death. Secondary outcomes included arrhythmia recurrence. Results A total of 467 patients were included with mean 4.6 ± 1.7 years follow-up, of whom 48 (10.3%) had silent PVs. The silent PV group had had more often undergone >1 prior ablation (45.8% vs 9.8%; p <0.001), had more persistent AF (62.5% vs 41.1%; p =0.005) and had more non-PV ablation performed both at prior ablation procedures and at the analysed redo ablation. The primary outcome occurred more frequently in those with silent PVs (25% vs 13.8%; p =0.053). Arrhythmia recurrence was also more common in the silent PV group (66.7% vs 50.6%; p =0.047). After multivariable adjustment, female sex (aHR 2.35 [95% CI 2.35–3.96]; p =0.001) and ischaemic heart disease (aHR 3.21 [95% CI 1.56–6.62]; p =0.002) were independently associated with the primary outcome, and left atrial enlargement (aHR 1.58 [95% CI 1.20–2.08]; p =0.001) and >1 prior ablation (aHR 1.88 [95% CI 1.30–2.72]; p <0.001) were independently associated with arrhythmia recurrence. Whilst a finding of silent PVs was not itself significant after multivariable adjustment, this provides an easily assessable parameter at clinically indicated redo ablation which informs the clinician of the likelihood of a worse future prognosis. Conclusions Patients with silent PVs at redo AF ablation have worse clinical outcomes.