Role of Non-Pulmonary Vein Triggers in Outcomes of First-Time Atrial Fibrillation Ablation

Pulmonary veins (PVs) are major sources of atrial fibrillation (AF) triggers, but patients may also have non-PV (NPV) triggers. Data on the impact of targeting NPV triggers on AF ablation outcomes are limited.

This study aimed to assess the outcome of patients undergoing AF ablation based on their NPV trigger status.

Patients undergoing first-time AF ablation using radiofrequency energy between 2018 and 2023 who received trigger provocative maneuvers were included. The provocative maneuvers consisted of cardioversion of AF, incremental isoproterenol infusion (3, 6, 12, and 20-30 μg/min) and/or an atrial burst pacing protocol. NPV triggers were defined as ectopic foci initiating AF, sustained focal atrial tachycardia (AT), or atrioventricular nodal reentrant tachycardia. Recurrence was defined as AF/AT >30 seconds after a 90-day blanking period.

Of 2,315 patients included, 2,046 (88.4%) did not have NPV triggers, 233 (10.1%) had NPV triggers that were ablated, and 36 (1.6%) had NPV triggers that were not targeted or failed localization/ablation attempts. One-year recurrence rate was 29.5% in patients without NPV triggers, 38.2% in those with ablated NPV triggers (adjusted HR: 1.35; 95% CI: 1.08-1.69), and 72.2% in those with untreated NPV triggers (adjusted HR: 3.71; 95% CI: 2.48-5.54). This response pattern remained consistent regardless of NPV trigger subtype (AF vs focal AT) or provocation method (spontaneous vs induced triggers).

Failure to ablate induced NPV triggers is associated with a high risk of recurrence. Although the ablation of NPV triggers reduces recurrence rates to levels approaching those without such triggers, their presence indicates a modestly worse prognosis.