Hi Carola,
As George and Carey noted above, it is not that your trusty ablation failed, once ablation lesion lines hold up with zero recurrence for at least a full year and a half, it's highly unlikely for those scar lines to ever fail, and thus allow AFIB/aflutter to trigger again from the same previously ablated spots that were solid so long. The old adage that AFIB can't cross a durable mature scar is still very much valid.
What can happen, especially for people who had a very successful Natale (or any other operators successful PVI-only ablation) that are usually now well over a decade ago, is that the progression eventually can move on well past the PVI antrum/Posterior wall isolation areas of the left atria that typically defined the limits of ablation target zones up until roughly late 2007 into 2008 when Dr Natale began pioneering expansion of more advanced ablation techniques to include ablating all of those much further out frontier areas of both the left and right atria located beyond the usual initially ablated PVAI antrum areas of the left atria that defined the maximum extension of early stage PVI/PVAI ablation target zones.
Want we have seen frequently over the last 10 plus years (again as noted above), is that eventually the underlying progression of AFIB outstrips the range of the initial standard PVI anatomical-only ablation protocol's sphere of effect within the atria.
AFIB generally, and in the vast majority of cases, begins its progression close to and around the four pulmonary veins, including the antral area immediately surrounding the four PVs, and begins to fan out, roughly analogous to the spread of a brush fire in the open prairie. The leading edge of this 'brush fire' is where the crux of the arrthymogenic triggering tends to manifest as it spreads further away from the origins of AFIB, in or around the PV zone. This leading edge 'hot zone' largely defines the active triggering at any point in the progression of AFIB as it gradually spreads eventually reaching the far frontier areas of both the left and right atria represented by the Coronary Sinus (CS) in the right atria, and left atrial appendage (LAA) in the frontier anterior part of the left atria.
A well done truly durable 'old school' PVI-only ablation, which even today is the limit to which at least 80% of EPs who offer an AFIB ablation to their patients will actually ablate too, and most still don't even look for any real time unique triggers beyond the anatomically described PVI region, we have found such relatively limited initial ablations will typically keep AFIB at bay for 10 to 11 years once they have been recurrence-free for at least 1.5 years or so.
More rarely such a limited anatomical PVI can last indefinitely, but usually this occurs only in those lucky folks who show very little, to no, progression of the disease beyond their PV antrum/posterior atrial wall zone where the disease initially manifests and was successfully buttoned down during what was, way back then before 2008 or so, the limits of AFIB ablation effect.
From the advent of the PVI first described in the seminal Bordeaux study published in October 1998 to the present, the majority of AFIB ablations still deal only with PVI or PVI plus posterior LA wall... some add the SVC too and all three zones are purely anatomical targets that don't require much, if any, real time electrophysiological sleuthing during the ablation to ferret out other Non-PV triggers where-ever such active triggers can be found.
The CS and LAA represent the furthest out structures in the both right and left atria with a similar enough morphology to the PV antrum area that they can sustain any atrial arrhythmia, be it AFIB, AFlutter or ATachycardia.
The evidence we have so far, is that once all the usual target zones around the PV antrum/LAPW/SVC plus active non-PV triggers spreading outward toward these last two structures of CS and LAA that can sustain atrial triggering, are all durably ablated/isolated, then there is no solid rationale for any more recurrence of any form of atrial arrhythmia to occur.
So, again Carola, it's not that your expert Extended Natale PVI with LAPW-iso ablation from 2007 has failed, but that your AFIB/aflutter progression has simply outstripped the limitations of what marked the limit of PVI type ablations from the early years of ablation technology.
Those lesions that Natale made in your left atria are still holding fast, but it appears your Arrhythmia has moved on to greener pastures with a very high likelihood that by now CS and/or LAA involvement may well be driving your recurrence.
No worries though, since Natale’s method and skills have also greatly evolved since the early generation PVAI that gave you a long and welcomed respite from the beast.
Your two choices now are, as Carey noted, either try an AAR drug since one of the benefits of having had a solid ablation originally is that often times AAR drugs that did fail before your index ablation, often now work much better and may be enough for you, at least for the time being.
The second, and in my view much preferred next step, is to revisit Dr Natale’s new state of the art EPLab at St Davids and begin what should certainly be the final leg of your AF experience once he can durably isolate these last few remaining structures in the RA and LA, such that no further battles with the beast should ever be expected.
While all of our current evidence with over 12 years of LAA isolation by Dr Natale to-date, strongly support the rationale that complete isolation of the LAA and CS (on top of previously successful extended Natale PVAI), should mark the end of all this gedoe once and for all. Nevertheless formal confirmation of that fact will require another decade or so of direct evidence.
I am on my 12th year + 4 months with not a single beat of AFIB since my index ABL with Dr Natale after having had AFIB/Flutter gradually progress to a highly aggressive persistent AFIB over 16 years before I, very thankfully, found my way to Natale’s table!
Thus, it's no surprise why I strongly recommend letting Dr Natale complete his Hat trick in your heart to restore the great result of durable NSR restored for the long term.
Finally, for some folks in your shoes, depending on one's age and overall health, there is a potential role for adopting an AAR drug like Flecanide (if you tolerate it well) and see if that is sufficient for you going forward. I still prefer the full fix ... but some scenarios, including in ones more advanced older age, can make the drug route worth considering too.
Cheers!
Shannon