Induction Test-Guided Ablation Improves Clinical Outcomes in Recurrent Atrial Fibrillation and Durable Pulmonary Vein Isolation

Background: In patients with recurrent atrial fibrillation (AF) despite durable pulmonary vein isolation (PVI), the optimal catheter ablation (CA) strategy remains unclear. Non-pulmonary vein (non-PV) foci contribute to AF recurrence, whereas the benefit of empirical posterior wall isolation (PWI) is inconsistent. Objective: To compare an induction test-guided ablation strategy with empirical PWI in patients with recurrent AF and durable PVI. Methods: We retrospectively analyzed 99 patients undergoing repeat CA with durable PVI, allocated to an induction test-guided ablation group (IT, n = 59) and an empirical PWI group (emp-PWI, n = 40). In the IT group, non-PV foci were identified and ablated. If ablation failed or no foci were induced, PWI was performed (IT-PWI subgroup); successful elimination of non-PV foci defined the IT-SE subgroup. The primary outcome was freedom from AF recurrence at 12 months. To minimize selection bias, we performed propensity score matching (PSM) using logistic regression and 1:1 nearest-neighbor matching with a caliper of 0.2. Results: In unmatched cohort, AF-free survival was higher with IT versus emp-PWI (75% vs. 56%; HR 2.3, 95% CI 1.13–4.52; p = 0.021). This advantage persisted after PSM (log-rank p = 0.016; HR 3.0, 95% CI 1.17–7.68; p = 0.022). Among the IT group, outcomes were similar between the IT-SE and IT-PWI subgroups (78% vs. 72%, p = 0.613). In the IT-PWI subgroup, residual non-PV foci were associated with higher recurrence (p = 0.023). Conclusions: In recurrent AF despite durable PVI, an induction test-guided ablation strategy was associated with greater freedom from AF recurrence compared to empirical PWI and this association remained after PSM.