Multiple epicardial connections during extensive pulmonary vein isolation

Area of Science:

• Electrophysiology
• Cardiac Ablation
• Atrial Fibrillation Treatment

Background:

• Pulmonary vein isolation (PVI) is a standard treatment for atrial fibrillation.
• Incomplete PVI can lead to atrial fibrillation recurrence.
• Identifying and ablating residual pulmonary vein connections is crucial for successful PVI.

Observation:

• A 76-year-old male patient undergoing PVI for atrial fibrillation experienced incomplete isolation of the left superior pulmonary vein (LSPV).
• High-resolution mapping revealed the earliest activation site (EAS) on the left atrial roof, outside the initial ablation line.
• Subsequent ablation at the identified EAS successfully isolated the LSPV, but reconnection occurred, necessitating further mapping and ablation at a different site on the atrial roof.

Findings:

• Targeting the earliest activation site (EAS) on the left atrial roof, identified through high-resolution mapping during LSPV pacing, was effective in isolating the LSPV.
• Multiple ablation applications targeting different EAS on the left atrial roof were required to eliminate LSPV reconnection.
• The presence of multiple residual connections suggests potential involvement of epicardial pulmonary vein-left atrial connections.

Implications:

• High-resolution activation mapping is valuable for identifying challenging pulmonary vein connections during atrial fibrillation ablation.
• Targeting specific EAS on the left atrial roof can resolve LSPV reconnection after initial PVI attempts.
• Understanding the role of epicardial connections may refine PVI strategies for complex atrial fibrillation cases.