Topological determinants of atrial tachyarrhythmia recurrence post-pulmonary vein antrum isolation

Abstract Background Pulmonary vein antrum isolation (PVAI) is a widely adopted procedure for treating atrial fibrillation (AF). However, atrial tachyarrhythmia recurrence is frequently observed post-ablation. The role of topological obstacles in recurrence patterns remains underexplored. Purpose This study aims to investigate the impact of topological obstacles on the recurrence patterns of atrial arrhythmias following PVAI. Methods Subjects who underwent de novo AF radiofrequency ablation between March 2019 and April 2024 were enrolled. Based on pre-ablation left atrium voltage maps, subjects were categorized into five groups according to the number of topological obstacles (1 to 5; see Figure). Post-procedural arrhythmia recurrence was classified as either AF or atrial tachycardia (AT) based on 12-lead electrocardiogram findings. Results A total of 238 subjects who underwent PVAI were analyzed (mean age: 62.1 ± 8.9 years; female: 23.9%; mean follow-up duration: 1.0 ± 0.5 years). The majority of subjects were classified into group 3 (61%), followed by group 4 (17%), group 1 (10%), group 2 (7%), and group 5 (3%). Subjects with one topological obstacle tended to be older (mean age: 67.3 ± 5.3 years), had more comorbidities (congestive heart failure, coronary artery disease, valvular heart disease), worse echocardiographic features (lower left ventricular ejection fraction and larger left atrium size), and the highest low-voltage area burden. Among all subjects, AF recurrence was most commonly observed during follow-up, followed by no recurrence, with AT recurrence being the least common. Among the recurred patients, subjects with either one or five topological obstacles were more likely to experience AF recurrence, with rates of 93.3% and 100%, respectively (Figure). Conclusion Patients with either very few or many topological obstacles are more prone to AF recurrence post-PVAI. Considering topological characteristics may help predict post-ablation arrhythmia recurrence patterns.