Contemporary strategies for repeat ablation of atrial fibrillation: a European Heart Rhythm Association survey

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Abstract
Aims: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. However, the optimal strategy during repeat ablation is not clear. This European Heart Rhythm Association (EHRA) survey aims to assess real-world ablation strategies in patients undergoing repeat AF ablation. Methods and results: A 25-item questionnaire was distributed among healthcare professionals via EHRA between 22 May and 21 June 2024. Of the 211 respondents from 43 countries, 58.1% of respondents planned a redo after multiple symptomatic recurrences of atrial arrhythmias. Most repeat procedures (68.0%) are performed within 3 months after the decision for re-intervention. 3D mapping and radiofrequency (RF) catheters with contact force (CF) sensing are the most common modality used for repeat ablation. In patients with more than one pulmonary vein (PV) reconnection, most commonly reisolation of the PVs plus individualized substrate-based ablation is performed (62.2%). When empirical ablation is performed, the most common targets include cavotricuspid isthmus (22.5%), posterior wall isolation (20.7%), left atrial roofline (16.1%), anterior line (12.9%), superior vena cava (8.6%), and vein of Marshall (8.6%). In patients without PV reconnection at repeat procedure, substrate mapping/individualized ablation is the preferred strategy (77.9%). No additional right atrial ablation beyond the CTI was reported. The majority of respondents (60.7%) consider rate control after ≥3 failed ablations. Conclusion: Real-world strategies for repeat AF ablation show significant variability. 3D mapping and CF-guided RF ablation are commonly utilized. Re-PVI and substrate-based ablation are the predominant approaches. However, the optimal strategy beyond durable PVI remains to be further evaluated.

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