Evaluation of Intraprocedural Strategies to Assess Acute Pulmonary Vein Isolation After First-Pass Wide Antral Circumferential Ablation

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Atrial fibrillation (n=58). Intervention: 3D electroanatomical remapping combined with targeted pacing vs. Pulmonary vein and carina pacing alone (20 mA output, 500 ms cycle length). Primary outcome: Discordance in detection of residual conduction at the left carina (cases identified exclusively by 3D remapping vs pacing alone) (p=0.002 (Holm-adjusted p = 0.011)).

Q: What does this research mean for the field?

High-density 3D electroanatomical remapping detects significantly more residual conduction in the left pulmonary veins and left carina than pacing assessment alone following wide antral circumferential ablation, identifying persistent conduction gaps in 41.4% of patients. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Lyuboslav Katov; Julian Ballweg; Yannick Teumer; Jonas Rostan; Federica Diofano; Carlo Bothner; Wolfgang Rottbauer; Karolina Weinmann

doi:10.3390/jcm15197654

October 2, 2026Journal of Clinical MedicineOpen Access

Evaluation of Intraprocedural Strategies to Assess Acute Pulmonary Vein Isolation After First-Pass Wide Antral Circumferential Ablation

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Why the study?

The optimal method for confirming complete acute pulmonary vein isolation after wide antral circumferential ablation remains uncertain.

Does comprehensive 3D electroanatomical remapping combined with targeted pacing improve the acute intraprocedural detection of residual electrical conduction compared to pacing maneuvers alone in patients with atrial fibrillation undergoing wide antral circumferential ablation?

Key Points

To evaluate the diagnostic concordance of pulmonary vein pacing versus repeat 3D electroanatomical mapping for confirming acute pulmonary vein isolation after wide antral circumferential ablation.
Prospective observational study of 58 patients with paroxysmal (41.4%) or persistent (56.9%) atrial fibrillation undergoing bilateral wide antral circumferential ablation between November 2023 and April 2025 at University Heart Center Ulm.
Following ablation, pacing was delivered from each pulmonary vein and carina at a maximal output of 20 mA, followed by high-density 3D electroanatomical re-mapping to identify residual electrical conduction.
First-pass pulmonary vein isolation occurred in 26 of 58 patients (44.8%), and systematic 3D remapping uncovered at least one residual conduction site in 24 of 58 patients (41.4%).
Pacing assessment alone produced significantly more false-negative results than 3D remapping in the left upper vein (p = 0.039), left inferior vein (p = 0.012), and left carina (p = 0.002; adjusted p = 0.011).
No significant discrepancies between pacing and 3D remapping were observed for right-sided veins or the right carina (p = 0.453), with overall agreement ranging from 75.9% at the left carina to 91.4% at the right inferior pulmonary vein.

Study Design

Type

Observational (n=58)

Blinding

Open-label

Multicenter

No

Structured PICO

Does comprehensive 3D electroanatomical remapping combined with targeted pacing improve the acute intraprocedural detection of residual electrical conduction compared to pacing maneuvers alone in patients with atrial fibrillation undergoing wide antral circumferential ablation?

P

Population

58 adults (median age 73 years, 32.8% female) with paroxysmal or persistent atrial fibrillation undergoing first-pass wide antral circumferential ablation, assessed intraprocedurally.

E

Exposure

Comprehensive high-density three-dimensional (3D) electroanatomical remapping of the left atrium (using Carto with OctaRay/PentaRay or Rhythmia with Orion mapping catheters, >=1000 EAM points, bipolar voltage thresholds 0.1 and 0.5 mV) combined with targeted pacing to assess acute pulmonary vein and carina isolation immediately following initial bilateral radiofrequency WACA (50 W or 90 W/4 s).

C

Comparator

Pulmonary vein and carina pacing maneuvers alone (performed at an output of 20 mA with a cycle length of 500 ms at four predefined sites around each PV ostium and anterior/posterior aspects of each ipsilateral carina) performed immediately after completion of initial bilateral WACA prior to 3D remapping.

O

Outcome

Intraprocedural detection of residual electrical conduction (defined as absence of both entrance and exit block) and diagnostic agreement/discordance between pacing-based and mapping-based assessments across six anatomical regions (LUPV, LIPV, RUPV, RIPV, left carina, and right carina) immediately post-WACA.surrogate

Main Result

Absolute Event Rate: 22.4% vs 1.7%

p-value: p=0.002 (Holm-adjusted p = 0.011)

Following wide antral circumferential ablation for atrial fibrillation, pulmonary vein pacing alone frequently misses residual conduction in the left pulmonary veins and left carina compared to high-density 3D electroanatomical remapping, supporting the complementary use of 3D remapping in left-sided regions to verify acute isolation.

Limitations

Relatively small sample size (n=58) and single-center observational design
Absence of randomization
Sequential rather than independent performance of pacing-based and mapping-based assessments
Lack of an independent diagnostic reference standard
Analysis restricted to acute verification of PVI without long-term clinical follow-up or assessment of lesion durability
Detailed segmental gap localization, post-WACA remapping duration, and exact number of additional RF applications were not systematically captured
Relatively small sample size (n=58) and single-center, observational design
Restricted to acute intraprocedural verification without long-term follow-up on lesion durability, PV reconnection, or clinical outcomes

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Implication

Pacing may miss left-sided gaps after PVI; leaves open whether routine high-density remapping improves durable isolation.

Abstract

Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. While pulmonary vein isolation (PVI) remains the cornerstone of AF ablation, the optimal method for confirming complete acute isolation remains uncertain. This study evaluated the diagnostic value of pulmonary vein (PV) pacing compared with repeat three-dimensional (3D) electroanatomical mapping following wide antral circumferential ablation (WACA). Methods: In this prospective observational study, 58 patients with paroxysmal or persistent AF undergoing bilateral WACA at the University Heart Center Ulm between November 2023 and April 2025 were included. Following successful PVI, pacing was performed from each PV and the corresponding carina region using a maximal stimulation output of 20 mA. Subsequently, comprehensive 3D re-mapping was performed to reassess electrical conduction. Results obtained from pacing maneuvers were compared with repeat mapping findings. Results: The study population had a median age of 73 (62.7–78.2) years and a median body mass index of 26.8 (24.0–29.9) kg/m2. Median left atrial diameter was 4.8 (4.3–5.5) cm, and moderate to advanced atrial fibrosis was present in approximately one-third of patients. For the left-sided PVs, pacing assessment alone was associated with a significantly higher proportion of false-negative results compared with 3D re-mapping (left upper PV: p = 0.039; left inferior PV: p = 0.012). In contrast, no significant differences were observed for the right PVs. Evaluation of the carina regions showed a similar pattern, with a significant discrepancy on the left side (p = 0.002) but not on the right side (p = 0.453). Conclusions: PV pacing alone may not reliably identify residual conduction within the left PVs and left carina after WACA. Additional 3D re-mapping appears valuable in these regions to detect persistent conduction gaps that could otherwise remain unnoticed. For right-sided PVs, pacing-based assessment may provide sufficient confirmation of acute isolation in many cases. These findings support a complementary use of both techniques to improve procedural verification of PVI. Larger prospective studies are warranted to confirm the observed results and determine their clinical implications.

Discussion

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Cite This Study

Katov et al. (2026) conducted an observational in Atrial fibrillation (n=58). 3D electroanatomical remapping combined with targeted pacing vs. Pulmonary vein and carina pacing alone (20 mA output, 500 ms cycle length) was evaluated on Discordance in detection of residual conduction at the left carina (cases identified exclusively by 3D remapping vs pacing alone) (p=0.002 (Holm-adjusted p = 0.011)).

synapsesocial.com/papers/6ac1ab93cc6172083c928973 https://doi.org/10.3390/jcm15197654

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Evaluation of Intraprocedural Strategies to Assess Acute Pulmonary Vein Isolation After First-Pass Wide Antral Circumferential Ablation

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Evaluation of Intraprocedural Strategies to Assess Acute Pulmonary Vein Isolation After First-Pass Wide Antral Circumferential Ablation

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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