Key result
Late pulmonary vein reconnection drives recurrent atrial fibrillation months after index PVI.
Why the study?
The mechanism of delayed recovery of pulmonary vein conduction after initially successful pulmonary vein isolation is unknown and requires further investigation.
Case Report (n=1)
Late pulmonary vein reconnection can occur up to 11 months post-ablation, highlighting the need to understand mechanisms of delayed conduction recovery such as cellular regeneration or fibroblast bridging.
Late PV reconnection at 11 months post-PVI should not change practice; leaves open mechanisms and optimal surveillance duration.
A 51-year-old with paroxysmal atrial fibrillation underwent pulmonary vein isolation (PVI) (P1). Pre-ablation pulmonary vein (PV) potentials (*) were noted in all PVs [Panel A; left superior pulmonary vein (LSPV) shown]. Post-ablation entrance and exit block (†) was documented in all PVs. (Panel 1B and C) Repeat procedure (P2) was performed 5 months after index PVI for clinical recurrence. Left-sided PVs remained isolated (entrance and exit block; Panel 1D and E). Conduction recovery was documented in the right-sided PVs, which were re-isolated. A third ablation procedure (P3) was performed 11 months after index PVI for clinical recurrence. Spontaneous conduction recovery was observed into the previously isolated LSPV (Panel 1F). Although early PV–reconnection is suspected to result from deficiencies of the index ablation procedure, the mechanism of delayed recovery of PV conduction is unknown. Recent clinical and pre-clinical studies have suggested it may be related to: (i) persistence of a dynamic cellular substrate within the zone of ablation, whereby regenerative resident cardiac cell populations generate a sufficient mass of local cardiomyocytes to electrically ‘bridge’ a previously disconnected zone between PV and left atrium (LA); and (ii) fibroblast strands, which play a central role in cardiac repair and scar tissue formation. Although previously believed to passively couple to cardiomyocytes (thus slowing conduction), recent studies have shown them capable of restoring conduction between cardiomyocyte clusters in culture. Clearly, we need to learn more about the fundamental mechanisms leading to resumption of LA–PV conduction after an initially successful procedure. The full-length version of this report can be viewed at: http://www.escardio.org/communities/EHRA/publications/ep-case-reports/Documents/late-pulmonary-vein-reconnection.pdf
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Andrade et al. (2013) conducted a case report in paroxysmal atrial fibrillation (n=1). Pulmonary vein isolation was evaluated on Late pulmonary vein reconnection and clinical recurrence. A 51-year-old patient with paroxysmal atrial fibrillation experienced late pulmonary vein reconnection and clinical recurrence 5 and 11 months after index pulmonary vein isolation.
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