Author + information
- Received September 29, 2016
- Revision received December 7, 2016
- Accepted January 11, 2017
- Published online June 19, 2017.
- Pouria Alipour, BSca,
- Zahra Azizi, MDa,
- Meysam Pirbaglou, MScb,
- Paul Ritvo, PhDb,
- Alfredo Pantano, MDa,
- Atul Verma, MDa and
- Yaariv Khaykin, MDa,∗ ()
- aHeart Rhythm Program, Southlake Regional Health Centre, Newmarket, Ontario, Canada
- bFaculty of Health, School of Kinesiology, York University, Toronto, Ontario, Canada
- ↵∗Address for correspondence:
Dr. Yaariv Khaykin, Heart Rhythm Program, Southlake Regional Health Centre, #602-581 Davis Drive, Newmarket, Ontario L3Y 2P6, Canada.
Objectives This study sought to determine the exact period after pulmonary vein antrum isolation (PVI) during which early recurrence of atrial tachyarrhythmia (ERAT) does not predict late arrhythmia recurrence (LR), in order to better define the blanking period.
Background Recurrence of atrial fibrillation after PVI is not uncommon. The first 3 months after PVI have been commonly treated as a blanking period, during which ERAT is not thought to predict LR after PVI; however, recent studies have shown that ERAT does predict LR.
Methods Baseline and follow-up data for 636 patients (mean age: 61.4 ± 10.6 years; 67.1% male; 59% paroxysmal atrial fibrillation; 31.4% ERAT) who underwent PVI between 2010 and 2014 were included. Recurrences were monitored by electrocardiography and Holter monitoring at 1-, 3-, 6-, 9-, and 12-month intervals post-procedure. Receiver-operating characteristic curve analysis was used to define the blanking period after PVI.
Results Overall, 51%, 76%, and 92% of patients who had ERAT in the first, second, and third month post-PVI, respectively, also experienced LR (p = 0.001). Using a logistic regression model, those manifesting ERAT during the first, second, and third month post-PVI were 4.22, 9.03, and 19.43 (p = 0.001) times more likely to experience LR, respectively, compared to those without ERAT. Furthermore, receiver-operating characteristic analysis revealed that 23 days post-PVI is the optimal cutoff date for the blanking period, with area under the curve of 0.7, sensitivity of 69.2%, and specificity of 61.2%.
Conclusions The likelihood of experiencing LR progressively rises with ERAT after the first month post-PVI. Blanking period after PVI should be limited to the first 23 days clinically and in future studies.
- atrial fibrillation
- blanking period
- early recurrence
- early recurrence of atrial tachyarrhythmia
- late recurrence
- pulmonary vein isolation
Radiofrequency catheter ablation has been used for pulmonary vein antrum isolation (PVI) in patients with paroxysmal atrial fibrillation (PAF) and persistent atrial fibrillation (AF) (1–5). Early recurrence of atrial tachyarrhythmia (ERAT), common during the initial 90 days after ablation, has been reported by most investigators, ranging in incidence from 6.7% to 65% because of the varying definitions of the post-ablation blanking period (6–10). This blanking period or therapy stabilization period is defined as a period of time post-ablation during which any recurrence of AF, atrial flutter (AFL), or atrial tachycardia (AT) is not considered a failure of the procedure nor is it suggestive of long-term AF recurrence (8,9,11,12). According to the 2012 Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation, a blanking period of 3 months should be used to report efficacy of AF ablation procedures (11). Proposed causes of early recurrence during the blanking period include post-ablation inflammation, short-term autonomic imbalance, and the required time for maturation of lesions (7,9,10,12,13). Although these factors may not predispose patients to late recurrence (LR), studies have shown a relationship between these early recurrences and late arrhythmia recurrences after 3 months (3,9,12). The time point at which transient reversible post-ablation factors yield to reconnection of the pulmonary veins (PVs) as the cause of early arrhythmia recurrence has not been precisely established (12). Recent studies have looked at early recurrences at different time points between 48 hours to 3 months with respect to their predictive ability for LRs (9,10,12). However, to date, no study has used receiver-operating characteristic (ROC) analysis of early arrhythmia recurrences as a predictor of LR, using time during the first 3 months as a continuous variable. Therefore, we conducted this study to find the time point post-PVI during which transient factors responsible for ERAT reflect an established substrate for arrhythmia recurrence, using ROC analysis to determine the scientific basis for the blanking period.
Baseline and follow-up data for 636 consecutive patients (mean age: 61.4 ± 10.6 years; 67.1% male; 59% PAF, 31.4% (n = 200) ERAT) who underwent their first PVI between 2010 and 2014 were prospectively collected and included in the analysis. Patients were stratified into 2 groups based on the presence of ERAT post-procedure. Additionally, patients were divided into those with PAF and those with persistent atrial fibrillation (NPAF). All patients had follow-up information available for at least 12 months post-PVI. Any documentation of atrial tachyarrhythmia (AT) during follow-up was noted and included for consideration in the study. Patients who had at least one episode of atrial arrhythmia (AF, AT, or AFL) in the first 90 days were included in the study. All data collection was reviewed and approved by the institution’s research ethics board. This study did not interfere with any patient’s standard of care and was strictly a prospective cohort study.
Amiodarone was discontinued at least 3 months before the procedure; all other antiarrhythmic drugs (AADs) were discontinued at least 5 half-lives before the ablation. All patients were prescribed oral anticoagulants (OACs) at least 1 month before the procedure and continued for at least 3 months post-procedure. Transesophageal echocardiography was performed on the day of the procedure to ensure the absence of left atrial appendage thrombus in all patients. In brief, for the ablation procedure, vascular access was obtained using the right and left femoral veins as well as the right internal jugular vein. A coronary sinus catheter was placed via the right internal jugular vein, and an intracardiac echocardiography (ICE) probe were placed in the right heart via the left femoral vein (AcuNav, Siemens, Washington, DC). Transseptal access to the left atrium was established under fluoroscopic and ICE guidance, and the irrigated ablation catheter (ThermoCool or Surround Flow, Biosense Webster, Diamond Bar, California) along with a decapolar circular mapping catheter (Biosense Webster) were placed in the left atrium via independent transseptal punctures under ICE guidance. The patients were systemically anticoagulated, maintaining an activated clotting time between 300 and 350 s. Three-dimensional electroanatomic representation of the left atrium and the PVs was created using the CARTO 3 (Biosense Webster) 3-dimensional electroanatomic mapping system. Power was titrated between 30 and 40 W. Esophageal temperature was not routinely monitored during the procedure. Radiofrequency energy was delivered, guided by the circular mapping catheter in order to eliminate local electrograms across the PV antra and the posterior wall from the ridge between the left PVs and the appendage, across the entire roof and posterior wall of the left atrium to the septal aspect of the right PVs as previously described (14). Using this approach, entrance block was achieved; however, PV exit block was not routinely assessed, nor did the patients receive adenosine to assess for dormant PV conduction after ablation. In all patients the entire lesion set was verified during sinus rhythm (remapped in those who required cardioversion or converted from AF with ablation after establishment of sinus rhythm). Each vein was rechecked at least 20 min after it was initially isolated. Isoproterenol challenge was not used during the index ablation, nor were non-PV foci targeted beyond the lesion set as described. All patients who underwent ablation were treated using the same approach. After 24 h of close monitoring for post-procedural complications, patients were discharged home. Follow-up visits were scheduled at 3, 6, 9, and 12 months post-procedure.
Follow-up and reporting
Post-procedure, patients continued taking OACs for at least 3 months. Further use of OACs was determined using the Canadian guidelines (11). Patients who were taking AADs before the procedure resumed taking them for the first 3 months after the procedure. The drugs were discontinued at the 3-month follow-up if no documented recurrence of atrial tachyarrhythmia was observed. AADs were offered to patients with symptomatic recurrences of AF, but for patients who were refractory to or intolerant of medical therapy, a redo procedure was offered.
Patients were monitored closely post-procedure for recurrences of symptomatic and asymptomatic AF. An ambulatory ECG was performed 1 and 4 weeks post-ablation, and 14-day Holter monitoring was performed 4 to 6 weeks post-procedure. Further ambulatory monitoring (48-h Holter) and ECG were performed at the 3-, 6-, 9-, and 12-month follow-up visits and every 6 months thereafter, as well as during any unscheduled ambulatory visits related to arrhythmia recurrence. For any patient with an implantable cardiac rhythm management device, the device was interrogated for arrhythmia burden at each clinic visit. Any manifestation of atrial tachyarrhythmia was noted and recorded in the study database and subsequently used in the data analysis. For those patients who underwent repeat ablation, their procedural data were collected and subsequent visits documented in the database. Recurrence was defined as any atrial tachyarrhythmia (AF or any organized tachyarrhythmia such as AFL) documented and lasting at least 30 s.
In our study, any recurrences of AF, AFL, or AT within 90 days post-ablation were defined as ERAT, and any recurrences of AF, AFL, or AT from 3 to 12 months or more post-ablation were defined as LR.
All continuous variables are expressed as mean ± SD, and categorical variables are expressed as frequency and percentage. Between-group differences in demographic and clinical characteristics were evaluated using independent-sample Student t test for continuous variables and chi-square tests of independence for categorical variables. Using ROC, we evaluated an ideal time point with highest sensitivity and specificity to empirically define a blanking period. Subsequently, separate multivariate logistic regression models were used to assess the likelihood of late arrhythmia recurrence based on time to ERAT within the 90-day post-ablation window stratified according to the conventional (i.e., monthly classification) time period or the time period derived using ROC analysis. Both regression models considered patients without ERAT during the blanking period as the reference group. Statistical analyses were performed using SPSS software, version 22 (IBM Corp., Armonk, New York).
Demographic and clinical characteristics
Baseline demographic and clinical characteristics of the study participants are given in Table 1. Study participants included a total of 636 AF patients, 200 (31.4%) of whom experienced ERAT within the 90-day blanking period.
Among the 200 patients with ERAT, 118 (59%) had PAF and 82 (41%) manifested NPAF. Mean left atrial size was 41.1 ± 8.5 mm in patients with ERAT, and nearly 86% had a mean ejection fraction of 60% or higher. Hypertension was present in 61% of the patients, along with congestive heart failure (11%), structural heart disease (11%), and type 2 diabetes mellitus (9%). There were statistically significant differences between PAF and NPAF patients, including body mass index (28.6 kg/m2 in PAF, 30.2 kg/m2 in NPAF; p = 0.05) and frequency of amiodarone failure before ablation (22% in PAF, 35.4% in NPAF; p = 0.03). In addition, a significantly greater proportion of NPAF patients had a history of congestive heart failure (6.0% in PAF, 17.2% in NPAF; p = 0.01) and structural heart disease (4.2% in PAF, 19.5% in NPAF; p = 0.001) (Table 1). Prevalence of ERAT differed between PAF and NPAF patients (31.5% [27.2% PAF, 40.3% NPAF; p = 0.011]).
Overall, 242 patients (137 [68.5%] ERAT, 105 [24.1%] no ERAT) had LR, of whom 153 underwent a redo procedure (96 [48%] ERAT, 57 [13%] no ERAT). Prevalence of LR differed between PAF and NPAF patients (35.8% PAF vs. 42.9% NPAF; p = 0.001). All patients who underwent reablation had PV reconnection of at least one PV.
Of the 436 patients (68.6%) without ERAT, 315 (72.2%) were diagnosed with PAF and 121 (27.8%) were diagnosed with NPAF before the ablation. In patients without ERAT, mean left atrial size was 39.9 ± 8.6 mm, and 89.4% of patients had a mean ejection fraction of 60% or higher. Similarly, 61.5% were diagnosed with hypertension, 10.1% with congestive heart failure, 13% with structural heart disease, and nearly 7.3% with type 2 diabetes mellitus. As with participants who experienced ERAT, there were statistically significant differences between PAF and NPAF patients, specifically with regard to gender distribution (68.7% men in PAF and 31.3% men in NPAF; p = 0.02) and amiodarone failure rate before ablation (16.1% in PAF and 42% in NPAF; p = 0.001). In addition, a significantly greater proportion of NPAF patients had structural heart disease (8.8% in PAF and 24% in NPAF; p = 0.001), congestive heart failure (6.7% in PAF and 19% in NPAF; p = 0.01), type 2 diabetes mellitus (4.8% in PAF and 14% in NPAF; p = 0.001), and hypertension (57.1% in PAF and 72.7% in NPAF; p = 0.001).
Overall, 566 patients (89%) (n = 186 [92.5%] with ERAT [PAF: 108 (91.5%), NPAF: 78 (94%); p = 0.51] and n = 380 [87.2%] without ERAT [PAF: 273 (86.7%), NPAF:107 (89.2%); p = 0.48]) were taking at least one AAD for the first 3 months after the procedure. Based on logistic regression, use of AAD post-procedure did not show any significant influence on the likelihood of LR (p = 0.11).
ROC curve for defining the ideal cutoff point for the blanking period post-PVI
An ROC curve was used to determine the accurate cutoff time point based on sensitivity and specificity of ERAT for LR to better define the blanking period post-PVI. Our analysis determined 23 days to be the ideal cutoff point for the blanking period with area under the curve of 0.70 (95% confidence interval [CI]: 0.633 to 0.778; p < 0.001), along with sensitivity and specificity of 69.2% and 61.2%, respectively (Figure 1).
AF recurrence within the blanking period and the likelihood of LR
Among the patients with ERAT, early recurrence of AF occurred during the first month post-ablation in 50% of the patients (60% PAF and 40% NPAF; p = 0.77), with an additional 31% of patients (32.3% PAF and 29.3% NPAF; p = 0.65) experiencing an ERAT within the second month post-ablation. Rates of ERAT progressively declined over the 3-month blanking period, with nearly 80% of ERAT (83% PAF and 78% NPAF) occurring within the first 2 months post-ablation (Figure 2). In patients with ERAT, LR of AF symptoms occurred in 137 patients (68.5%), with a slightly higher rate in NPAF patients (65.3% PAF and 73.1% NPAF; p = 0.09). In patients without ERAT, LR occurred in 105 patients (24%), with similar rates in both PAF and NPAF patients (24.7% PAF and 22.3% NPAF; p = 0.60). Rates of LR were significantly different between those experiencing ERAT and those without ERAT, regardless of AF type (73.1% vs. 24%; p = 0.0001). Timing of ER during the blanking period was significantly associated with the rate of LR, with the likelihood of LR progressively increasing in association with the delay between ablation and the ERAT event (51% in the first month, 75.8% in second month, and 92.1% in third month; p = 0.0001) in both patients with PAF (46% in the first month, 68% in the second month, and 95% in third month; p = 0.0001) and those with NPAF (57% in the first month, 87% in the second month, and 88% in third month; p = 0.008) (Figure 3). ERAT was stratified by type of arrhythmia (AF vs. AFL vs. AT). Overall, 157 patients (78.5%) manifested AF, whereas 28 patients (14%) and 15 patients (7.5%) manifested AFL and AT, respectively. Of the 242 patients with LR, 188 manifested AF (77.7%), 32 AFL (13.2%), and 22 AT (9.1%). Furthermore, there was no relationship between the type of ERAT manifestation and the likelihood of LR (p = 0.11). Arrhythmia documented at the time of LR was consistent with that documented during ERAT.
Using univariate logistic regression, potential factors contributing to the manifestation of LR were analyzed. This model revealed age (odds ratio [OR]: 1.02; 95% CI: 1.01 to 1.04; p = 0.001), ERAT (OR: 6.73; 95% CI: 4.65 to 9.73; p = 0.0001; ERAT in first month: OR: 4.35; 95% CI: 2.76 to 6.85; p = 0.0001; ERAT in second month: OR: 9.06; 95% CI: 4.92 to 16.67; p = 0.0001; ERAT in third month: OR: 20.80; 95% CI: 7.92 to 54.65; p = 0.0001), number of failed AADs (OR: 1.33; 95% CI: 1.14 to 1.57; p = .001), and history of the patient having failed amiodarone (OR: 1.66; 95% CI: 1.14 to 2.41; p = 0.009) as significant predictors of LR (Table 2). Gender, body mass index, ejection fraction, AAD use after ablation, and structural heart disease were not significant predictors of LR. Factors deemed as significant univariate predictors were then entered into the multivariate logistic regression (Tables 3 and 4).
Subsequently, 2 multivariate logistic regression models were built using timing of ERAT classified according to the month after ablation and stratified around the 23-day cutoff. These models revealed progressively greater odds for LR based on ERAT in the first (OR: 4.22; p = 0.0001), second (OR: 9.03, p = 0.0001), and third months (OR: 19.43; p = 0.0001) after the procedure compared to patients without ERAT during the conventional blanking period (Table 2). Greater odds for LR depending on ERAT stratified around the 23-day cutoff (OR: 4.41; p = 0.0001 for ERAT before 23 days vs. OR: 9.27 for ERAT after 23 days; p = 0.0001) compared to patients without ERAT during the 3-month post-ablation period (Table 3). Both models included adjustments for the impact of other covariates, including age, AF type (PAF vs. NPAF), number of failed AADs, and history of the patient having failed amiodarone.
By considering the blanking period of 3 months, studies have reported ERAT rates ranging from 15.9% to 65%, with a pooled estimate of 37.8% (7–9). Although more than 90% of these arrhythmias take place within the first 10 days post-ablation, ERAT may also occur up to 3 months post-ablation (7,15–17). The rate of early recurrence in our study was 50% in the first month, 31% in the second month, and 19% in the third month, and cumulatively 80% of all ERAT occurred in the first 2 months. Our study showed a significant decline in the incidence of AF over the 3-month period post-PVI, whereas the likelihood of LR progressively increased with timing to ERAT during the first 3 months after ablation (OR: 4.22, 9.03, and 19.43 for the first, second, and third month post-ablation, respectively; p < 0.001). Of note, all patients who were taking an AAD before the procedure continued taking their medication for at least 3 months after ablation. Patients who did not manifest any ERAT in the initial 90 days discontinued taking their AADs, whereas those who experienced at least one episode of ERAT lasting at least 30 s within the same time period continued taking the medication. To address this issue further, we ran a logistic regression model to determine the effect of ongoing AAD therapy on ERAT. Based on this analysis, ongoing AAD therapy did not significantly affect the likelihood of LR (p = 0.11). Our findings are consistent with a study by Leong-Sit et al. (18), which investigated the effects of AADs on LR of AF. Although use of AADs had some effect on reducing early recurrences, there was no significant differences between the control group and an interventional group with respect to the risk of LRs. They are also consistent with a study by Joshi et al. (19), who showed the highest ERAT prevalence rate of 54% in the first 2 weeks and a subsequent decline to a minimum of 22% ERAT in the third month.
Several factors have been identified as predictors of late arrhythmia recurrence post-PVI. ERAT has been described as an independent predictor of LR in several studies (2,5,9,19,20). Our group previously described early recurrence as the strongest predictor of LR, with a hazard ratio of 4.87 (95% CI: 3.88 to 6.12; p = 0.0001) (14,21). This result was comparable to the study by Maroto et al. (15) of 106 patients post-ablation, which showed early recurrence as a risk factor for LR with a hazard ratio of 3.45. Several other prior studies (3,7,9,12) have demonstrated that a majority of patients experiencing ERAT during the first 3 months post-PVI are more vulnerable to LR (53.7% patients with ERAT vs. 6.9% patients without ERAT) (12). This study supports a significant association between timing of ERAT and the rate of LR. Rate of LR was 51% in those who had ERAT in the first month, and 75.8% and 92.1% among those who had ERAT in the second and third months, respectively (p < 0.001). Similarly, Bertaglia et al. (22) reported LR rates of 56.7% and 80% with ERAT in the first month and 2 subsequent months, respectively.
Transient factors (post-procedure inflammation, autonomic imbalance, and lesion maturation time) likely play an important role in some early episodes of ERAT (3,7,9,12). A study by Lim et al. (10) of 90 patients with AF assessing proinflammatory responses after radiofrequency ablation showed an inflammatory response and myocardial injury 3 days after ablation that was associated with early AF recurrence during the same time frame. Additionally, the degree of inflammatory response was also associated with early AF recurrence during this time. Their study demonstrated that one-half of the patients who experienced early recurrence within 30 days had LR, whereas all patients who had episodes between 30 days to 3 months after ablation experienced LR as well; therefore, they concluded that inflammatory responses after ablation usually are limited to the first month post-ablation (10). According to these findings, there has been some discussion among investigators regarding the modifying effect of steroids and other anti-inflammatory substances after ablation and findings supporting its efficacy in ERAT reduction as well as improving mid-term outcomes (9,10,23). A study by Koyama et al. (24) of 186 patients post-PVI, assessing proinflammatory factors and their relationship with AF recurrence, revealed that patients with immediate recurrence (occurring within 3 days after ablation) had a higher AF-free rate of 76% than did those with early AF recurrence (occurring between 4 and 30 days post-ablation) of 30% during 6-month follow-up. The exact time at which the predictive power of early recurrences for LRs rises, reflecting when the early transient factors responsible for arrhythmia recurrences yield to PV reconnection, was not firmly established (2,5,9,19,20,25–28).
In a study by Hsieh et al. (29), 1 month was described as the time required for recovery of autonomic function (including changes in heart rate and heart rate variability). Maturation of the ablation lesions in other studies has been estimated to occur within 1 to 2 weeks after ablation (3,12).
A recent study by Das et al. (12) of 40 patients with paroxysmal AF, setting the blanking period at 1 month, showed that any ERAT beyond 4 weeks post-PVI was significantly associated with PV reconnections at follow-up electrophysiological study. In their study, patients were monitored using a 30-second electrocardiogram daily as well as for symptoms. Regardless of their symptom status, the patients underwent electrophysiological study 2 months after PVI to evaluate the number of reconnected PVs and to assess the correlation between the first and second month’s ERAT with PV reconnection. The study demonstrated that ERAT occurring in the first month was not correlated with PV reconnection, whereas ERAT occurring in or persisting into the second month was strongly correlated with PV reconnections. On the contrary, a study using cardiac magnetic resonance imaging to evaluate the lesions reported 3 months as the time required for formation of left atrial scar tissue after ablation (30). A study by Themistoclakis et al. (20) investigated 1,298 patients who were followed for 41 ± 10 months at 1, 3, 6, 9, and 12 months post-ablation and then every 6 months thereafter using a monitoring protocol similar to that used in our study. Patients were further followed using transtelephonic rhythm transmissions and 48-hour Holter monitoring as symptoms dictated, and their ERATs were classified according to the time of their first occurrence.
According to their study, the incidence of ERAT was higher in the first month, specifically in the first week (incidence rate of 81%), with a decline in the second and third months (incidences of 10% and 9%, respectively). LR was more frequent in patients who experienced ERAT in the third (98%) and second months (69%) than in those who experienced ERAT in the first month (44%). Additionally, the investigators showed that the first recurrence in the second and third months after ablation has a stronger association with LR than ERAT during the first month (first month OR: 20; second month OR: 54; third month OR: 1052; p < 0.001 for all findings).
Our findings demonstrate that after controlling for the effects of age, AF type, left atrial size, and other comorbidities, ERAT within the second and third months of the blanking period is a significant predictor of LR, with OR of 9.03 (p = 0.0001) and 19.43 (p = 0.0001), respectively. However, no relationship was found between ERAT type (AF vs. AFL vs. AT) manifestation and the likelihood of LR (p = 0.11).
The likelihood of LR in patients with ERAT during the initial 23 days post-PVI was 4.41. In contrast, patients with recurrent episodes after 23 days had an LR likelihood of 9.27. In addition, comparing each month separately revealed a likelihood of 4.22, 9.03, and 19.43 for LR during the first, second, and third months post-ablation, respectively.
ROC curve yielded the best combination of sensitivity and specificity for ERAT predicting LR at 23 days post-ablation. Any ERAT beyond 23 days yielded an insignificant increase in specificity for a significant tradeoff in sensitivity. The rate of LR for patients with ERAT did not differ between PAF and NPAF groups. The novelty of this approach compared to the previous studies involves use of ROC analysis to establish the ideal cutoff time after which any early recurrence has a significantly higher likelihood of predicting late arrhythmia recurrences. Our results confirm 23 days post-ablation as the time point beyond which any ERAT heralds an established substrate for arrhythmia recurrence and should be treated as such rather than “blanked out.” Although our findings are in general agreement with previous studies, they narrow down the duration of the “blanking period” after PVI to 23 days.
This was an observational, nonrandomized prospective cohort study conducted at single large tertiary electrophysiology center. All ablation procedures were performed using radiofrequency energy, and the findings may not be applicable to ablation procedures performed using other commonly used forms of energy delivery such as cryoablation. Finally, we did not use intensive monitoring by transtelephonic monitoring or implantable loop recorder to rule out asymptomatic recurrences during the first 90 days post-PVI and instead followed a more feasible clinical protocol.
Based on the findings of this study, 23 days or about 3 weeks (rather than 3 months) post-AF ablation appears to be an appropriate cutoff for the blanking period. Any recurrence of arrhythmia after the initial 23 days post-ablation should be considered clinically significant. Further studies should be directed to evaluate the ideal timing of a repeat ablation procedure for patients experiencing early recurrences, stratified into early intervention for any recurrence following the 3-week cutoff versus a strategy of waiting to intervene after recurrences occur following the current conventional 3-month blanking period.
COMPETENCY IN MEDICAL KNOWLEDGE: This study demonstrates that the traditional 3-month definition of the blanking period post-PVI is not accurate because recurrences happening past the first month post-ablation are a significant predictor of subsequent episodes of AF.
TRANSLATIONAL OUTLOOK: By narrowing the blanking windows to 23 days, clinicians can better inform and set more realistic expectations for patients and their families.
Dr. Verma has received grants from Biosense Webster, Medtronic, Bayer, and Boehringer; and has served on the advisory boards of Biosense Webster and Bayer. All other authors have reported they have no relationships relevant to the contents of this paper to disclose. Francis Marchlinski, MD, served as Guest Editor for this paper.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Abbreviations and Acronyms
- antiarrhythmic drug
- atrial fibrillation
- atrial flutter
- atrial tachycardia
- confidence interval
- early recurrence of atrial tachyarrhythmia
- intracardiac echocardiography
- late recurrence
- persistent atrial fibrillation
- oral anticoagulant
- odds ratio
- paroxysmal atrial fibrillation
- pulmonary vein
- pulmonary vein antrum isolation
- Received September 29, 2016.
- Revision received December 7, 2016.
- Accepted January 11, 2017.
- 2017 American College of Cardiology Foundation
- Mulder A.A.,
- Wijffels M.C.,
- Wever E.F.,
- Boersma L.V.
- Oral H.,
- Knight B.P.,
- Özaydın M.,
- et al.
- Kawasaki S.,
- Tanno K.,
- Ochi A.,
- et al.
- Roux J.-F.,
- Zado E.,
- Callans D.J.,
- et al.
- Eitel C.,
- Piorkowski C.,
- Hindricks G.
- Lim H.S.,
- Schultz C.,
- Dang J.,
- et al.
- Calkins H.,
- Kuck K.H.,
- Cappato R.,
- et al.
- Das M.,
- Wynn G.J.,
- Morgan M.,
- et al.
- Phillips K.P.
- Khaykin Y.,
- Oosthuizen R.,
- Zarnett L.,
- et al.
- Ishii Y.,
- Gleva M.J.,
- Gamache M.C.,
- et al.
- Leong-Sit P.,
- Roux J.F.,
- Zado E.,
- et al.
- Alipour P.,
- Khaykin Y.,
- Pirbaglou M.,
- et al.
- Koyama T.,
- Tada H.,
- Sekiguchi Y.,
- et al.
- Mugnai G.,
- de Asmundis C.,
- Hünük B.,
- et al.
- Andrade J.G.,
- Khairy P.,
- Macle L.,
- et al.
- Hsieh M.-H.,
- Chiou C.-W.,
- Wen Z.-C.,
- et al.