Repeat vs Index Ablation for Atrial Fibrillation

Catheter ablation tools
Catheter ablation tools
Repeat catheter ablation was found to be safe and to have efficacy comparable with index ablation in alleviating symptoms in patients with atrial fibrillation.

Repeat catheter ablation was found to be safe and to have efficacy comparable with index ablation in alleviating symptoms in patients with atrial fibrillation (AF), according to a study published in Clinical Research in Cardiology.

Despite standardized pulmonary vein isolation during index ablation, arrhythmia recurrence caused by reconnected pulmonary veins, often indicates the need for repeat procedure. However, index vs repeat ablation for AF have not extensively been compared in a real-world population.

In this multicenter prospective study, data from the German Ablation Registry was used to enroll 4155 symptomatic patients with AF >18 years who underwent catheter ablation between January 2007 and January 2010. Participants were divided into 2 groups: index ablation (n=3377; 82.1%; median age, 62 years; 33.5% women), and repeat ablation (n=738; 17.9%; median age, 63 years; 29.1% women).

The primary outcomes evaluated procedural safety and success, and included major adverse cardiac events (MACE; myocardial infarction [MI], or death), major adverse cardiac and cerebrovascular events (MACCE; stroke, MI, or death), and a composite safety endpoint (MI, stroke, major bleeding, or death). Secondary outcomes included long-term success, survival, safety metrics, and qualitative measures such as satisfaction with therapy and quality of life. Follow-up was conducted at 30 days and 1 year.

There was a greater percentage of patients experiencing paroxysmal AF at baseline in the index vs repeat ablation group (69.3% vs 61.9%, respectively; P <.001), but lower rates of persistent AF (30.7% vs 38.1%, respectively; P <.001).

For patients in the repeat vs index ablation group fluoroscopy time (27 min vs 29 min, respectively; P <.001) and procedure length (163.6 min vs 181.2 min, respectively; P <.001) were shorter, mean dose area product was lower (3325 cGy x cm2 vs 3744 cGy x cm2, respectively P =.001), and mean duration of radiofrequency application was shorter (1960 s vs 2580 s, respectively; P <.001).

At 1 year, MACE (0.4% vs 0.3%, respectively; P =.58), MACCE (0.8% vs 0.6%, respectively; P =.47), mortality (0.3% vs 0.1%, respectively; P =.39), arrhythmia recurrence (43.8% vs 41.9%, respectively; P =.37), and the composite safety endpoint (1.5% vs 1.4%, respectively; P = .76) were comparable in the index vs repeat ablation groups. Symptomatic improvement was similar between the groups, with 80.4% and 77.8% of patients reporting reduced or no symptoms after 1 year in the index and repeat ablation groups, respectively (P =.13). Both severe nonfatal (1.6% vs 2.4%; P =.20) and moderate nonfatal (8.3% vs 7.6%; P =.60) adverse events occurred at comparable rates in the index vs repeat groups, respectively.

A majority of patients in the index and repeat ablation groups reported full (62.9% vs 61.2%, respectively) or partial (21.6% vs 24.7%, respectively) satisfaction with the procedure and outcome.

Study limitations include use of less advanced technology and different anticoagulation regimens than are currently employed, possible unknown confounders, potential selection and reporting biases, likely underestimation of recurrence rates, and the heterogeneous nature of care at different centers.

“Repeat ablation may offer symptomatic relief in patients with atrial fibrillation with high safety. Despite progressive forms of AF and more severe symptoms, the effects seem to be comparable [with] index ablation,” noted the authors.

Funding and Conflicts of Interest Disclosures:

Please see original article for conflict of interest declarations.


Kany S, Brachmann J, Lewalter T, et al. Safety and patient-reported outcomes in index ablation versus repeat ablation in atrial fibrillation: insights from the German Ablation Registry. Clin Res Cardiol. October 2020. doi:10.1007/s00392-020-01763-1