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

ABSTRACT 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.