PMC:6019327 / 73432-76912
Annnotations
{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/6019327","sourcedb":"PMC","sourceid":"6019327","source_url":"https://www.ncbi.nlm.nih.gov/pmc/6019327","text":"The Mechanisms of AF Recurrence After Catheter Ablation or Surgical AF Ablation\nAlthough its efficacy has been established, both catheter and surgical ablation of AF are associated with a substantial risk of AF recurrence.251,252 It is important to recognize that late recurrences are often asymptomatic.56 Recurrences of AF after ablation are generally classified into three types according to the phase after ablation in which they appear: (1) early recurrence (within 3 months); (2) late recurrence (from 3 months to 1 year); and (3) very late recurrence (more than 1 year). The characteristics and optimal managements differ according to the type of recurrence.\nEarly recurrence, which is defined as recurrence within the first 3 months after the procedure, is observed in 50% or more of patients.253,254,255 Although its precise mechanisms have not been fully elucidated, the possible causes include (1) a transient stimulatory effect of the tissue inflammatory response to the application of RF256; (2) a transient imbalance of the ANS257; and (3) a delayed effect of the application of RF, likely due to the maturation of the ablation lesion soon after the procedure.258 A “blanking period” of 3 months after the procedure, during which reintervention should be avoided, is recommended because up to half of the patients with early recurrence remain AF-free during long-term follow-up.254,255,259 It has recently been shown that patients who experience multiple early recurrences, especially more than a month postablation, are more likely to have an unsuccessful response to AF ablation at 1-year follow-up. It is for this reason that some electrophysiologists recommend early reablation in this subset of patients.260\nLate recurrence, during the first 9 months after the blanking period, occurs in 25%–40% of cases261,262; however, the incidence differs depending on the patient population (ratio of paroxysmal to persistent form) and the manner in which recurrence is screened for and detected. Studies have shown that the mechanism for late-term recurrence is predominantly linked to the recovery of electrical conduction between the PVs and the LA, irrespective of the type of AF.261,263 Accordingly, ongoing efforts are focused on identifying techniques to achieve permanent PVI during an initial AF ablation procedure.264,265\nThe incidence of very late recurrence (after more than 12 months postablation) has been shown to be higher than previously expected. Multiple studies of long-term follow-up data (more than 5 years) have demonstrated that the longer the follow-up postablation, the higher the recurrence rate.266,267,268 The predominant mechanism of very late recurrence includes PV reconnection, the development of non-PV triggers, and development and maturation of substrate.267,269,270 The predictors of the very late recurrence of AF appear to be the nonparoxysmal form of AF at baseline, organic heart disease (valvular heart disease and cardiomyopathy), advanced age, and obesity.268,271\nOne study investigated the relationship between time to recurrence of AF following AF ablation, response to therapy, and outcome.272 This study found that time to recurrence is a major determinant of outcome. Patients with later recurrences were more likely to have sporadic episodes and respond better to AADs and repeat ablation. This observation suggests pathophysiological differences based on time to recurrence, and have implications for clinical 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