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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e87

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

2 Studies have evaluated the use of different end-

points immediately after catheter ablation for predicting durable PVI and the likelihood of future arrhythmias with mixed results.19–28 In the largest randomized study to date, techniques such as waiting for 30 minutes, using adenosine triphosphate to facilitate PV reconnection, or the combination of waiting and using adenosine were not superior to no testing for predicting durable pulmonary vein isolation or reduction in future arrhythmias. Although noninducibility remains important in determining whether ablation for paroxysmal SVT has been successful, noninducibility after AF ablation or termination of AF with ablation have had mixed results for predicting the likelihood of future recurrence.19–29 Multiple ablation targets beyond PVI have been

evaluated in randomized controlled and observational trials, including the LAA, posterior wall, the ligament of Marshall, or atrial scar.8–18 Results have been mixed, and no strategy has emerged that is broadly applicable in all patients, likely because the individual mechanisms for AF vary from patient to patient.8–18 Targeting large areas of atrial tissue may have potential negative consequences, including a higher likelihood of complications such as atrioesophageal fistula, poor LA mechanics, atypical flutters, and increased risk for stroke.30–35

8.4.3 Management of Recurrent AF After Catheter Ablation

Recommendations for Management of Recurrent AF After Catheter Ablation Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 B-NR 1 In patients with recurrent symptomatic AF after

catheter ablation, repeat catheter ablation or antiarrhythmic drug therapy is useful to improve symptoms and freedom from AF.1–11

2a A 2 In some patients who have undergone catheter

ablation of AF, short-term antiarrhythmic drug therapy after ablation can be useful to reduce early recurrences of atrial arrhythmia and hospitalization.12–16

Synopsis Recurrences of AF are common after a first ablation procedure, occurring in 30% to 40% of patients in contemporary clinical trials.1,2 In general US practice, 11% of patients undergoing de novo ablation have a repeat ablation by 1 year.3 Patients often experience improved symptoms and QOL even when they experience recurrence after catheter ablation.4 Nonetheless, recurrent atrial arrhythmia that leads to symptoms or LV dysfunction requires treatment. Recommendation-Specific Supportive Text 1.	 In general, successful suppression of AF improves

with additional or multiple ablation procedures.5–7 The absolute limit to the number of ablations a patient can undergo is unknown. For example, it is possible that a patient with previous PVI and repeat ablations with substrate modification may benefit from ablation of PV to LA reconnections, or ablation of additional triggers. However, repeat ablations carry increased risks of adverse effects. These risks are rare but include PV stenosis and stiff LA syndrome.8,9,17

Many of the randomized clinical trials, which have

demonstrated superiority of catheter ablation over antiarrhythmic drug therapy, included repeat ablation procedures as part of their prospective study designs.1,10,11,18 Randomized data also suggest that repeat ablation is superior to antiarrhythmic drug therapy for the treatment of recurrent AF after first ablation.19 Although no large direct head-to-head trials are available of repeat catheter ablation versus no repeat catheter ablation, the aggregate data from randomized trials suggest that repeat ablation improves arrhythmia suppression and symptom control. Limited numbers of randomized trials can guide the optimal approach to repeat catheter ablation (beyond reisolation of the PVs).12,13 Although randomized data suggest that repeat ablation is superior to antiarrhythmic drug therapy for the treatment of recurrent AF after first ablation,19 recurrences of AF after catheter ablation can also be successfully treated with antiarrhythmic drug therapy even when these same medications may have been ineffective before ablation.3,14 Antiarrhythmic drugs have also been associated with decreased recurrent atrial arrhythmias in those who have undergone previous ablation.14 Other studies have shown that use of previously ineffective antiarrhythmic therapy can be effective after ablation.15 Optimal rhythm control often requires a combined approach of catheter ablation and adjunctive antiarrhythmic drug therapy, especially in patients with long-standing persistent AF or patients with advanced atrial myopathies. 2.	 Several clinical trials have demonstrated the

efficacy and safety of short-term (3-6 months postablation) antiarrhythmic therapy to prevent recurrences of AF, symptoms, cardioversion, and hospitalization after ablation.16,20,21 Moreover, continued use of antiarrhythmic drugs beyond the blanking period (3 months) may reduce the risk of recurrent atrial arrhythmias out to 1 year.15 Metaanalysis of randomized trials evaluating the use of short-term antiarrhythmic drug therapy have determined that it significantly decreases the risk of early, but not late, recurrence.22,23 Observational data from nationwide practice data also suggest that antiarrhythmic therapy after ablation can reduce hospital readmissions by 37% in the

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