Empirical Superior Vena Cava Isolation in Recurrent AF After PVI Ablation

Use of a strategy that involves additional superior vena cava isolation at repeat pulmonary vein isolation (PVI) ablation for recurrent atrial fibrillation (AF)/atrial tachycardia does not improve patient outcomes compared with use of a PVI-only approach, according to the results of a study published in the Journal of Interventional Cardiac Electrophysiology.

The researchers sought to evaluate the role played by an empirical strategy of superior vena cava isolation in addition to pulmonary vein (PV) re-isolation during a repeat procedure in patients who experience AF recurrence following index PVI. They performed a nonrandomized, registry-based, dual center study.

Consecutive patients with documented AF recurrence with a duration of longer than 30 seconds after index PVI, who received a repeat ablation at 1 of 2 centers between 2010 and 2017, were analyzed retrospectively. Although only a re-isolation of the pulmonary vein was intended in individuals with reconnections of 2 or more pulmonary veins (PVI group), an additional superior vena cava isolation was planned for those patients with fewer than 2 isolated pulmonary veins in addition to the re-isolation of the pulmonary vein (PVI+ group). The analyses were performed in an as-treated and per-protocol basis. 

A total of 344 participants were enrolled in the study. PVI only was performed in 269 patients, and PVI plus superior vena cava isolation was performed in 75 patients (as-treated). Overall, 73% of the participants were men and 66% had paroxysmal AF. The mean patient age was 60±10 years.

Median follow-up after a repeat PVI was 320 days, and no statistically significant difference was reported between the 2 groups (PVI group: 265±113 days [median, 313 days] vs PVI+ group: 273±112 days [median, 350 days]; P =.822).

Freedom from AF/atrial tachycardia following repeat PVI was 80% in the PVI group compared with 73% in the PVI+ group (P =.151). Per multivariable Cox regression analysis, the presence of persistent AF (hazard ratio [HR], 2.067; 95% CI, 1.389-3.078; P <.001) and hypertension (HR, 1.905; 95% CI, 1.218-2.980; P =.005) were recognized as the only statistically significant predictors of AF/atrial tachycardia  recurrence. Results of the per-protocol analysis did not differ from these findings.

Some limitations of the study are that a relatively small number of patients with superior vena cava isolation are included. Further, the ablation strategy used (additional superior vena cava isolation in participants with ≤1 reconnected pulmonary vein and PVI in participants with ≥2 reconnected pulmonary veins) is not performed in all of the patients, because the decision regarding the strategy used was ultimately made at the discretion of the physician.

“A strategy of an empirical additional [superior vena cava isolation] at repeat PVI ablation for recurrence of AF/[atrial tachycardia] does not improve outcomes compared to a PVI only approach,” the study authors noted. “This holds true for the as-treated and per-protocol analysis as well for patients with paroxysmal AF. The only independent predictors of recurrence after repeat PVI were the presence of hypertension and persistent AF type.”

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

Reference

Knecht S, Zeljkovic I, Badertscher P, et al. Role of empirical isolation of the superior vena cava in patients with recurrence of atrial fibrillation after pulmonary vein isolation-a multi-center analysis. J Interv Card Electrophysiol. Published online August 18, 2022. doi:10.1007/s10840-022-01314-w