Triggering pulmonary veins: a paradoxical predictor for atrial fibrillation recurrence after PV isolation

To identify procedural parameters predicting recurrence of atrial fibrillation (AF) after a first circumferential pulmonary vein isolation (CPVI).

One hundred seventy-one patients undergoing CARTO-guided CPVI for recurrent AF with a left atrial (LA) diameter <45 mm were studied. Follow-up (symptoms and 7-day Holter) was performed at 1 and 3 months and every 3 months thereafter. Clinical and procedural characteristics between successful patients and patients undergoing repeat ablation were compared. In addition, procedural parameters of the first procedure were compared with parameters during repeat ablation.

After first CPVI, 80% of patients were free of AF without antiarrhythmic drugs after a follow-up (FU) of 28 +/- 11 months (N = 136). Thirty-five patients (20%) had recurrence of AF of which 25 underwent repeat ablation (N = 25). Clinical characteristics did not differ between the successful and repeat group. A triggering vein during the index procedure was significantly more observed in the repeat group (56% vs 11%, P < 0.001). At repeat ablation, 2.6 +/- 1.2 veins per patient were reconnected. Whereas there was no preferential reconnecting PV, all PVs triggering at index were reconnected (100%).

(1) In patients with symptomatic recurrent AF, the presence of a triggering pulmonary vein during ablation is a paradoxical predictor for AF recurrence after PV isolation. (2) The consistent finding of reconnection of the triggering PV at repeat ablation, suggests that, in these patients, the triggering PV is the culprit vein and that reconnection invariably results in clinical AF recurrence. (3) The present study advocates a strategy of even more stringent PV isolation in case of a triggering PV.