Premature depolarization concealed in two pulmonary veins

A case is presented in which a premature depolarization emanated from a partially activated left inferior pulmonary vein, activated the entire left superior pulmonary vein, but did not activate the atria ("concealed"). The site of conduction block between each vein and the left atrium was the anatomic atriovenous junction. At times, the same depolarization would activate the atria and initiate atrial fibrillation. The shortest depolarization coupling interval that activated the atria was significantly longer than the atrial fibrillation cycle length recorded in either vein. Observations in this case support two concepts: (1) the existence of myocardial "tracts," extending into and between pulmonary veins; and (2) a "mismatch" between pulmonary vein activation ingress and egress.