Current understanding of atrial fibrillation recurrence after atrial fibrillation ablation: From pulmonary vein to epicardium.

Abstract

Recurrence of atrial fibrillation (AF) after catheter ablation is common, with pulmonary vein (PV) reconnection considered the most likely cause. However, technologies such as contact force-sensing, irrigated catheters, and ablation index (AI)-guided ablation strategies have resulted in more durable PV isolation. As a result, it is difficult to predict which patients will develop AF recurrence despite durable PV isolation, with evolving non-PV atrial substrates thought to be a key contributor to late recurrences. Deciphering the complex mechanisms of AF recurrence beyond the cornerstone of PV isolation therefore remains challenging. Recently, there have been several important advances that may lead to better understanding and treatment of this challenging clinical entity: percutaneous epicardial access and mapping, late gadolinium enhancement magnetic resonance imaging (LGE-MRI), improvements in high-resolution electroanatomic mapping, and new ablation energy sources, specifically pulsed-field ablation. This review aims to synthesize the current literature in an effort to better understand arrhythmia mechanisms and treatment targets in patients with AF/Atrial tachycardia (AT) recurrence post-ablation.