A-Fib Ablation: Should You Worry About Recurrence or Reconnection?

Catheter ablation illustration at A-Fib.com

Illustration: Isolating a Pulmonary Vein during a catheter ablation

Background: Catheter ablations techniques for Atrial Fibrillation differ primarily in the energy source used to destroy the targeted heart tissue. These include extreme heat (RF ablation), extreme cold (Cryoballoon ablation), or the newest using short, high-energy electrical pulses (Pulsed Field Ablation). Recurrence can occur after any type of catheter ablation.

“Recurrence” or “Reconnection” is a general term used by Electrophysiologists (EPs) to describe any A-Fib that reoccurs after a catheter ablation. They often use one of three terms when referring to recurrence based on how soon it occurs after a catheter ablation: Early recurrence (usually within the first three months), late recurrence (1 year or later), or extreme late recurrence (5 years or decades later).

Causes of Recurrence

Self-Healing Recurrence/Reconnection. Heart tissue is very tough and resilient. There is a tendency for ablated heart tissue to heal itself and reconnect the ablated or isolated area. This can lead to A-Fib signals occurring again. If this happens, it most often occurs within the first three to six months following catheter ablation.

This may happen because the heart tissue was not originally ablated properly, or the burn lesion may not have been deep enough (transmural) to achieve permanent blocking.

Gap Reconnection. Ablating the targeted heart tissue requires manual dexterity, tactile sense and intense focus to make sure there are no gaps between the ablations; for example, when making a circular lesion line around the opening of a Pulmonary Vein. If a significant gap is left, this may result in recurrence. The A-Fib signal escapes from the Pulmonary Vein through this gap into the rest of the left atrium, thereby producing A-Fib again.

During the ablation, EPs have strategies to find any gaps. After isolating areas of tissue, they use a drug like adenosine to try to stimulate A-Fib and identify any gap locations. They may instead or in addition wait 30 minutes or longer to observe if there is any reconnection.

Post-ablation, it’s also possible that once swelling from the burn lesions subsides, gaps may appear which were hidden by the swelling. In this case you may need a short touch-up ablation to ablate the gaps.

Non-PV Ablation Sources of A-Fib. Not all A-Fib signals originate from the Pulmonary Veins (the most common source). EPs use specialize catheters and mapping techniques to track and identify the origin of A-Fib triggers. These sources are commonly found in the left atrial appendage, left atrial posterior wall, crista terminalis, coronary sinus, superior vena cava, or ligament of Marshall (see my note below).

Personal note: My “very late recurrence” occurred 21 years after my initial catheter ablation (you can read about it here). Among other A-Fib trigger areas, my “master” EP, Dr. Andrea Natale at Los Robles Hospital, found non-PV electrograms/potentials in the left atrial septum, the floor of the left atrium, the left atrial lateral wall, and the anterior roof of the left atrium which he eliminated with RF ablation. I’ve been A-Fib-free for the past 5 years.

Recurrences Due to Pre-Existing Conditions. There are health conditions which tend to cause A-Fib to recur, such as hypertension, obesity, sleep apnea, diabetes, smoking and binge drinking. Controlling these conditions will reduce the risk of recurrence.

For example, let’s say patient “Joe” has A-Fib and sleep apnea, then has a successful A-Fib ablation and is A-Fib free. But because of his sleep apnea, Joe’s A-Fib is more likely to recur than someone without sleep apnea. So much so, that Electrophysiologists (EPs) today are insisting that A-Fib patients with sleep apnea be treated and use devices like a CPAP breathing machine before they can have a catheter ablation. In one research study, sleep apnea was an independent predictor for catheter ablation failure after a single procedure.

Also, those with long-standing persistent A-Fib, or those with vascular heart disease, or cardiomyopathy are more likely to have a recurrence.

Your EP may not use the word ‘cure’, but the dictionary defines ‘cure’ as “restoration of health; recovery from disease.

What if You Have a Recurrence?

If you A-Fib returns, your EP does a “touch-up” ablation to ablate the reconnected tissue or gaps that are allowing A-Fib signals to affect the left atrium. This ablation will be much easier and faster than your original ablation.

On the other hand, if your A-Fib signals are found to originate from non-PV locations, a more specialized, highly skilled “master” EP may need to be consulted for your “touch-up” ablation.

What This Means to Patients

Catheter ablation today is the best hope of a “cure” for A-Fib. (Your doctors may not use the word ‘cure’, but the dictionary defines ‘cure’ as “restoration of health; recovery from disease.”) That should be your goal!

Let’s take a worst case scenario after your ablation:

You’re in good health and have no pre-existing medical conditions. Seven years after your ablation you have a recurrence of your A-Fib.

Think about that for a moment.

You’ve had seven years of a normal heart beat and a normal life! (Only those of us who’ve had symptomatic A-Fib know how wonderful it is to be A-Fib free―even if it’s just for three or five years, or whatever length of time.)

The Bottomline for A-Fib Patients: Don’t waste your life worrying about recurrence/reconnection. Live your life as though you are cured for the long term. You probably are.

For more about Recurrence, see my articles: Physical Activity Following Catheter Ablation: Significant Reduction of Atrial Fibrillation Recurrence; and After Two Years A-Fib Free, What Causes ‘Very Late Recurrence’ in Post-Ablation Patients?