What is the clinical evidence from this study?

Study design: Cohort. Population: Recurrence of atrial fibrillation after pulmonary vein isolation (n=344). Intervention: Empirical superior vena cava isolation (SVCI) plus pulmonary vein re-isolation vs. Pulmonary vein re-isolation (PVI) only. Primary outcome: Freedom from atrial fibrillation or atrial tachycardia (AF/AT) (p=0.151).

August 18, 2022Open Access

Role of empirical isolation of the superior vena cava in patients with recurrence of atrial fibrillation after pulmonary vein isolation—a multi-center analysis

Resultado clave

Empirical superior vena cava isolation in addition to pulmonary vein re-isolation did not significantly improve freedom from atrial fibrillation compared to pulmonary vein isolation alone (73% vs 80%, p=0.151).

Diseño del estudio

Tipo

Cohort (n=344)

Multicéntrico

Sí

PICO estructurado

Does empirical superior vena cava isolation in addition to pulmonary vein re-isolation reduce the recurrence of atrial fibrillation in patients undergoing repeat ablation?

Población

344 consecutive patients with recurrence of atrial fibrillation (AF) after index pulmonary vein isolation (PVI) undergoing a repeat ablation. Mean age 60 ± 10 years, 73% male, 66% paroxysmal AF. Multinational (2 centers in Switzerland and Croatia).

Intervención

Empirical superior vena cava isolation (SVCI) in addition to re-isolation of the pulmonary veins (PVI + group), intended for patients with < 2 isolated PV.

Comparador

Re-isolation of the pulmonary veins only (PVI group), intended for patients with reconnections of ≥ 2 PV.

Resultado

Freedom from atrial fibrillation or atrial tachycardia (AF/AT) after repeat PVI.composite

Empirical isolation of the superior vena cava during repeat ablation for recurrent atrial fibrillation does not improve arrhythmia-free survival compared to pulmonary vein re-isolation alone.

Resultado numérico

Tasa de eventos absoluta: 73% vs 80%

valor p: p=0.151

Limitaciones

Relatively small number of patients with SVCI
Non-randomized study design with baseline differences between groups
Ablation strategy was ultimately at the discretion of the physician rather than strictly protocolized
Exclusion of patients with additional lesions (e.g., mitral isthmus line, roof line)
Differences in antiarrhythmic drug continuation protocols between the two centers
Did not assess the length of the SVC sleeves or the potential due to the purely empirical strategy

Resumen

BACKGROUND: Non-pulmonary vein (PV) triggers play a role in the initiation of atrial fibrillation (AF), with the superior vena cava (SVC) being a common location. The aim of the current study was to investigate a strategy of empirical SVC isolation (SVCI) in addition to re-isolation of PV in patients with recurrence of AF after index PV isolation (PVI). METHODS: We retrospectively analyzed consecutive patients from two centers with recurrence of AF after index PVI, undergoing a repeat ablation. Whereas only a re-isolation of the PV was intended in patients with reconnections of equal or more than two PV (PVI group), an additional SVCI was aimed for in patients with < 2 isolated PV in addition to the re-isolation of the PV (PVI + group). Analysis was performed as-treated and per-protocol. RESULTS: Of the 344 patients included in the study (age 60 ± 10 years, 73% male, 66% paroxysmal AF), PVI only was performed in 269 patients (77%) and PVI plus SVCI (PVI +) in 75 patients (23%). Overall, freedom from AF/AT after repeat PVI was 80% (196 patients) in the PVI group and 73% in the PVI + group (p = 0.151). In multivariable Cox regression analysis, presence of persistent AF (HR 2.067 (95% CI 1.389-3.078), p < 0.001) and hypertension (HR 1.905 (95% CI 1.218-2.980), p = 0.005) were identified as only significant predictors of AF/AT recurrence. The per-protocol results did not differ from this observation. CONCLUSIONS: A strategy of an empirical additional SVCI at repeat PVI ablation for recurrence of AF/AT does not improve outcome compared to a PVI only approach.

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