Repeated provocation of time- and ATP-induced early pulmonary vein reconnections after pulmonary vein isolation: eliminating paroxysmal atrial fibrillation in a single procedure.

Background —Recurrence of Atrial fibrillation (AF) after successful pulmonary vein isolation (PVI) occurs mainly due to the reconnection of the once isolated PV. Although provocation and elimination of the early pulmonary vein reconnection (EPVR) soon after PVI has been widely performed to improve the outcome, AF recurrence due to subsequent PV reconnections still occurs. In this study, we repeatedly provoked and eliminated the EPVR to determine the appropriate procedural endpoint. Methods and Results —Seventy-five patients with paroxysmal atrial fibrillation (AF) underwent PVI. EPVR was provoked by both time- and ATP-induction every 30 min until 90 min after the individual isolation of all PVs. The number of re-connected atrio-PV gaps were evaluated and re-ablated at each provocation step. Although both time- and ATP-dependent EPVR was induced most frequently at 30 min after PVI (75 and 76 gaps, respectively), the prevalence of induced EPVR at 60 min was still high (64 and 36 gaps induced by time and ATP (respectively). Only a small number of EPVR appeared at 90 min after the elimination of all EPVR by 60 min, (8 gaps, p<0.01). During the mean follow-up period of 370 days, 92% of cases were free from AF without antiarrhythmic drugs. Conclusions —Provocation and elimination of time- and ATP-induced EPVR not only at 30 min but also at 60 min is recommended after PVI to improve its efficacy.