Long-term outcome following successful pulmonary vein isolation: Pattern and prediction of very late recurrence

Background: Despite encouraging results of pulmonary vein isolation (PVI) ablation for atrial fibrillation (AF), it is unclear whether there is genuine cure or there is an important attrition rate. We sought to determine the long-term outcome of the initial responders who experienced a prolonged AF-free complete response. Methods: From a series of 350 consecutive patients who underwent PVI for AF, 264 patients (75%) (males 71 %, age 57 +/- 12 years, paroxysmal AF 87 %) who demonstrated >= 1 year AF-free follow-up on no antiarrhythmic drugs were followed for 1-5 years. Results: During 28 +/- 12 months follow-up, 23 of 264 (8.7%) patients had recurrence of AF. The actuarial recurrence at 2 years postablation was 5.8 % and increased to 25.5 % at 5 years. Compared with long-term responders, more patients with late recurrence had hypertension (HR = 2.18, P = 0.009) and hyperlipidemia (HR = 4.01, P = 0.0005). Among 18 patients with recurrent AF necessitating repeat PVI, 15 (83 %) required re-isolation of > 1 PV and 28 of 45 (58%) PVs showed reconnection. All PVs were re-isolated and five (28%) patients had additional linear ablation. All 15 patients became AF-free again. Conclusions: Although most patients following PVI remain AF-free, some patients develop "late" recurrence of AF. The "late" recurrence patients are more likely to have hypertension and hyperlipidemia. Most late recurrences are associated with PV reconnections. Our observations emphasize the importance of continued long-term vigilance for AF recurrence, and also raise concerns regarding the need for long-term anticoagulation therapy.