Mechanisms of recurrent atrial fibrillation after pulmonary vein isolation by segmental ostial ablation.
OBJECTIVE
The aim of this study was to determine the mechanisms responsible for recurrent atrial fibrillation (AF) after pulmonary vein isolation (PV) by segmental ostial ablation.


BACKGROUND
Recovery of conduction into a previously isolated PV is a common observation when there is recurrent AF soon after segmental ostial ablation. However, the mechanisms of recurrent AF have been unclear.


METHODS
A repeat ablation procedure was performed in 50 patients who had recurrent paroxysmal AF at a mean of 7 +/- 6 months after segmental ostial ablation to isolate the PVs. During the repeat procedure, a ring catheter was inserted into each PV during sinus rhythm and AF to determine whether the veins were still isolated and, if not, whether there were PV tachycardias with a cycle length shorter than in the adjacent left atrium during AF.


RESULTS
There was recovery of conduction over a previously ablated muscle fascicle in >/=1 PV in 49 patients (98%). There were 10 +/- 2 episodes of PV tachycardia per minute in 36 (72%) of the 50 patients during AF. Repeat ablation was performed by segmental ostial ablation (23 patients) or by left atrial catheter ablation to encircle the left- and right-sided PVs 1 to 2 cm from the ostia, with additional ablation lines in the posterior left atrium and mitral isthmus (27 patients). At 6-month follow-up, among 23 patients who underwent repeat ablation by segmental ostial ablation, AF recurred in 4 (21%) of the 19 patients who had PV tachycardias and in 3 (75%) of the 4 patients who did not (P = .03). Among the 27 patients who underwent left atrial ablation, AF recurred in 2 (12%) of the 17 patients who had PV tachycardias and in 1 (10%) of the 10 patients who did not (P = 0.7).


CONCLUSIONS
Recovery of conduction in previously ablated muscle fascicles is a common finding in patients with recurrent AF after segmental ostial ablation. The efficacy of repeat segmental ostial ablation depends on the presence of PV tachycardias, whereas left atrial ablation is effective regardless of whether PV tachycardias are present or not during AF.
Lemola
Kristina
K
Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA.
Hall
Burr
B
Cheung
Peter
P
Good
Eric
E
Han
Jihn
J
Tamirisa
Kamala
K
Chugh
Aman
A
Bogun
Frank
F
Pelosi
Frank
F
Morady
Fred
F
Oral
Hakan
H
D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D016009:Chi-Square Distribution; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005500:Follow-Up Studies; D006329:Heart Conduction System / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D055502:Secondary Prevention; D016896:Treatment Outcome