Advancements in ablation technology lead to improved durability and outcome of pulmonary vein isolation using radiofrequency energy

During the last decade, pulmonary vein isolation (PVI) has become the most effective treatment for patients with atrial fibrillation. However, success rates after the first interventions were less favourable, creating durable PV isolation proved to be a technological challenge, consequently, repeated (redo) interventions were often performed.

Our objective was to examine how the proportions of redo PVIs and the PV reconnection rate have evolved in the practice of our institution in the light of the techological evolution of the past decade.

We retrospectively analyzed the demographic and procedural data of patients undergoing first PVI, using point-by-point radiofrequency (RF) technology between 2013 and 2024 in terms of technology used at index PVI, outcome during follow-up and PV reconnections at redo procedures. The RF technology was categorized using a scoring system, where irrigated-RF catheter technology was the basis (0 point), and each additional technological improvement used (contact force sensing, steerable sheath, Ablation Index, high power-short duration RF) increased the score by 1, up to a maximum of 4 points.

During the study period, 1580 patients underwent point-by-point RF PVI (60% male, age 62±10 years) and subsequently, 367 patients (23%) had redo interventions during the follow-up (25±26 months). The rate of first redo PVIs after index PVIs in ten years showed a significantly declining trend (53% in 2013, 6% in 2023, p<0.001). There was an inverse correlation between the technological points of the index procedures and the recurrence rate during follow-up (66%, 64%, 51%, 34%, 33%, in case of points 0 through 4, respectively, p<0.001). Lower technological score and persistent AF proved to be independent predictors of recurrence (p<0.001 and p=0.01, respectively). During the redo procedures, an inverse correlation was observed between the technology score of the index PVI and the rate of PV reconnection (88%, 99%, 74%, 59%, 46%, in case of points 0 through 4, respectively, p<0.001). Similarly, the number of reconnected PVs decreased with increasing score (a mean of 1.90, 2.0, 1.46, 1.23, 0.85 PVs, in case of points 0 through 4, respectively, p<0.001). In accordance with technological evolution, a significant increase was observed in the frequency of zero reconnection (0 points: 12%, 1 point: 11%, 2 points: 26%, 3 points: 41%, 4 points: 54%, p<0.001, Figure).

Paralell with the evolution of applied RF technology, the rate of redo PVI interventions, the phenomenon and extent of PV reconnection during redos have shown a significantly declining trend. These observations may reevaluate long-term management strategies for arrhythmia recurrences after PVI.

Figure