Acute and Chronic Pulmonary Vein Reconnection after Atrial Fibrillation Ablation: A Prospective Characterization of Anatomical Sites

Background: Arrhythmia recurrence after atrial fibrillation (AF) ablation is often associated with pulmonary vein reconnection (PVR). We prospectively examined anatomical sites of both acute and chronic PVR. Methods: One hundred and fifty AF patients underwent PV wide encirclement and sites where immediate electrical isolation (EI) occurred were tagged using electroanatomic mapping/CT integration (Cartomerge (TM), Biosense Webster, Diamond Bar, CA, USA). After 30 minutes PVs were checked and acute PVR sites marked at reisolation. Chronic PVR sites were marked at the time of repeat procedures. Results: On the left, immediate EI sites were predominantly on the intervenous ridge (IVR) and PV-left atrial appendage (PV-LAA) ridge. On the right they were at the roof, IVR, and floor of the PVs. Ninety-eight of one hundred and fifty patients had PVs checked after > 30 minutes. Thirty-two of ninety-eight had acute PVR. This was mostly on the IVR and PV-LAA ridge on the left (88%), and on the roof and IVR on the right (78%). At repeat procedure, 38/39 patients had chronic PVR, predominantly on the IVR (61%) and PV-LAA ridge (21%) on the left, and on the roof, IVR, and floor of the right PVs (79%). There was minimal acute or chronic PVR posteriorly. Acutely PVR occurred close to the immediate EI site 60% of the time, but only 30% of the time chronically. Conclusion: Acute and chronic PVR sites have a preferential distribution. This may be determined by anatomical and technical factors. Knowledge of immediate EI sites may be beneficial acutely, but with chronic PVR a careful survey is required. These findings may help target ablation, improving safety and success. (PACE 2008; 31:1598-1605).