While catheter ablation has demonstrated effectiveness in reducing AF burden and improving quality of life, recurrence remains a significant limitation, with studies reporting that up to 35% of patients require repeat ablation within the first few months of an initial procedure [8]. The patient described in this case experienced recurrent AF relatively soon after ablation, which is consistent with these reported recurrence rates and underscores the need for close post-procedural follow-up and consideration of early repeat intervention when appropriate.
Our patient also elevated BNP. In a study of 726 lone AF patients, multivariable analysis revealed the following factors to be independently associated with elevated BNP levels: older age, longer duration of AF, non-paroxysmal AF, and larger left atrial these data suggest an association between higher AF burden (chronicity, altered hemodynamics, and anatomic remodeling) and elevated BNP levels. Elevated BNP levels are also strong predictors of recurrent arrhythmia after ablation, which our patient had. Elevated BNP levels may reflect increased cardiac chamber wall stress and/or intrinsic atrial disease, thus increasing the risk of arrhythmia recurrence [11, 12].
Serial electrical cardioversion (ECV) has been investigated as a strategy to maintain sinus rhythm in patients with persistent and chronic atrial fibrillation (AF).
A study by Van Gelder et al. examined 123 patients with chronic AF undergoing repeated ECV in combination with antiarrhythmic drugs and anticoagulation. While initial restoration of sinus rhythm was achieved in 96% of patients, only 23% remained in sinus rhythm at one year. Importantly, the study demonstrated that serial ECV could be performed safely with appropriate anticoagulation, with no increase in thromboembolic complications compared to the general AF population. These findings established the feasibility of repeated cardioversion but highlighted the limited durability of rhythm control [13].
Bertaglia et al. addressed the problem of early AF recurrence, reporting that 57% of patients reverted to AF within one month after successful ECV, with the majority of relapses occurring in the first five days. They attributed this to fibrillation-induced electrical remodeling, characterized by shortened atrial refractory periods. Their study also showed that calcium-lowering pharmacologic agents reduced recurrence risk, suggesting a modifiable electrophysiologic substrate [14].
A study by Tieleman at al. provided randomized evidence supporting a structured serial ECV approach. In their trial of 101 patients, those assigned to repeated cardioversion achieved a 56% sinus rhythm maintenance rate at one year, compared with 26% in the single-ECV group (p < 0.01). This demonstrated that persistence with repeat procedures significantly improves rhythm outcomes [15].
In cases of refractory AF, this may include repeat ablation, atrioventricular nodal ablation with pacemaker placement, and comprehensive risk factor modification, such as management of sleep apnea, weight loss, blood pressure control, and lifestyle changes [16,17,18]. A multidisciplinary, patient-centered approach is essential to improve rhythm outcomes and reduce recurrence in patients with complex AF [19].
From a clinical standpoint, managing post-ablation AF recurrence comes with a high level of complexity, showcasing the value of individualized care planning, timely follow-up, and additionally treatment methods.