Differential Atrial Pacing to Detect Reconnection Gaps After Pulmonary Vein Isolation in Atrial Fibrillation

High-resolution mapping is useful to identify reconnection gaps in the pulmonary vein after pulmonary vein isolation for atrial fibrillation. However, it is sometimes difficult to differentiate pulmonary vein potentials from far-field potentials because of very low amplitudes. Our purpose was to evaluate the usefulness of a novel differential atrial pacing method to differentiate reconnected pulmonary vein potentials from isolated pulmonary vein potentials. This retrospective observational study included 34 patients with atrial fibrillation (22 men; mean age, 64 ± 14 years; 28 with paroxysmal atrial fibrillation) who underwent radiofrequency or cryoballoon ablation. Following pulmonary vein isolation, we created a high-resolution activation map during pacing from both the coronary sinus and left atrial appendage. We compared the characteristics of the pulmonary vein potentials and the pattern of activation between the reconnected and isolated pulmonary veins. We analyzed 131 pulmonary veins and found reconnections in 41 pulmonary veins (R group); 90 pulmonary veins had no reconnection (NR group). The R group had a significantly shorter distance between the earliest pulmonary vein activation sites in both activation maps, compared with the NR group (5.22 ± 0.53 mm versus 17.08 ± 0.36 mm, respectively; P < 0.0001). The amplitude of the pulmonary vein potentials was higher in the R group versus the NR group (0.61 ± 0.05 mV versus 0.04 ± 0.03 mV, respectively; P < 0.0001). Six gaps (14%) in the R group that were unrecognized using a conventional method were identified using our novel method. In conclusion, differential atrial pacing was useful to identify pulmonary vein reconnection gaps during ablation using a novel high-resolution mapping system.