High-voltage zones within the pulmonary vein antra: Major determinants of acute pulmonary vein reconnections after atrial fibrillation ablation.

PURPOSE: Recurrence of atrial fibrillation (AF) after pulmonary vein isolation (PVI) is mainly due to PV reconnections. Patient-specific tissue characteristics that may contribute remain unidentified. This study aimed to assess the relationship between the bipolar electrogram voltage amplitudes recorded from the PV-left atrial (LA) junction and acute PV reconnection sites.

METHODS: Three-dimensional LA voltage maps created before an extensive encircling PVI in 47 AF patients (31 men; mean age 62 ± 11 years) were examined for an association between the EGM voltage amplitude recorded from the PV-LA junction and acute post-PVI PV reconnections (spontaneous PV reconnections and/or ATP-provoked dormant PV conduction).

RESULTS: Acute PV reconnections were observed in 17 patients (36%) and in 24 (3%) of the 748 PV segments (16 segments per patient) and were associated with relatively high bipolar voltage amplitudes (3.26 ± 0.85 vs. 1.79 ± 1.15 mV, p < 0.0001) and a relatively low mean force-time integral (FTI) (428 ± 56 vs. 473 ± 76 gs, p = 0.0039) as well as FTI/PV-LA bipolar voltage (137 [106, 166] vs. 295 [193, 498] gs/mV, p < 0.0001). An analysis of the receiver operating characteristic curves revealed a high prognostic performance of the LA bipolar voltage and FTI/PV-LA bipolar voltage for acute PV reconnections (areas under the curve: 0.86 and 0.89, respectively); the best cutoff values were >2.12 mV and ≤183 gs/mV, respectively.

CONCLUSIONS: The PV-LA voltage on the PV-encircling ablation line and FTI/PV-LA voltage were related to the acute post-PVI PV reconnections. A more durable ablation strategy is warranted for high-voltage zones.