Recurrences of atrial fibrillation (AF) after pulmonary vein (PV) isolation (PVI) are mainly due to PV reconnections. However, a growing number of patients have recurrences despite durable PVI. The optimal ablative strategy for these patients is unknown.

We aimed at analyzing the impact of various ablation strategies in such patients in the context of a large multicenter study.

Patients scheduled for a redo ablation of AF and presenting durable PVI were included in 39 centers. PV-based, linear-based, electrogram-based and trigger-based ablation strategies were compared.

A total of 367 patients underwent a redo AF ablation procedure revealing a durable PVI (43.6% paroxysmal AF, 67.0% men, 63.4±10.2 years, CHA2DS2-VASc of 1.7±1.4) between 2010 and 2020. Regarding strategy combinations, 200 (54.5%) patients underwent a single ablation strategy, while 136 (37.1%) and 24 (6.5%) patients underwent a combination of 2 and 3 strategies, respectively. Following the redo ablation procedure, arrhythmia recurrence was observed in 122 patients (33.2%) at 12 months. The recurrence rate was not significantly different between paroxysmal and persistent AF groups (P=0.120). In multivariate analysis, none of the ablation strategies employed during the redo procedure improved the 12-month arrhythmia-free survival. The degree of left atrial dilatation (HR: 1.36, 95%CI: 1.13–1.65, P=0.002) was the only independent factor associated with arrhythmia-free survival at 12 months (Fig. 1).

In patients with recurrent AF despite durable PVI, no ablation strategy used during the redo procedure appears to be superior in improving the 12-month atrial arrhythmia free survival. The AF recurrence rate was the same whether the patient presented with a paroxysmal or persistent form of AF. Left atrial size is a major predictive factor of the arrhythmia-free survival in this population.