The Extent of Pulmonary Vein Electrical Connections Predicts the Success of Stand‐Alone Pulmonary Vein Isolation in Persistent Atrial Fibrillation

BACKGROUND: Identification of persistent AF (PsAF) patients who may be cured with stand-alone pulmonary vein isolation (PVI) would allow more efficient ablation strategies. Intuitively, the benefit of PVI is expected to be lower when PVs are poorly connected, but this assumption has never been tested. OBJECTIVE: Evaluate whether the circumferential extent of PV connections assessed pre-ablation predicts the success rate of PVI. METHODS: Consecutive patients with PsAF undergoing first ablation with stand-alone PVI were included. The extent of PV electrical connection was assessed using a circular mapping catheter and graded as limited, moderate, or extensive, according to tertiles of the mean numbers of bipoles recording PV potentials along the circumference of each vein. RESULTS: One hundred and forty-eight patients were included (age 64 ± 9.7 years, PsAF duration 7.3 ± 7 months). After a mean follow-up of 38.6 ± 7.8 months, freedom from arrhythmia recurrence after last PVI was significantly lower in patients with limited (38.6%), compared to moderate, and extensive PV connections (69.7% and 69%, respectively; p = 0.002). While redo PVI procedures did not significantly affect final ablation outcomes in patients with limited PV connections, a significant incremental arrhythmia-free survival gain was observed with increasing extent of PV connections (p < 0.01). CONCLUSIONS: The circumferential extent of PV connections is correlated to the success rate of PVI in patients with PsAF and may be a marker of the contribution of PVs to AF. The finding of limited PV connections may be used to select patients who may benefit from first-line adjunctive ablation.