AUTHOR=Kim Daehoon , Hwang Taehyun , Kim Min , Yu Hee Tae , Kim Tae-Hoon , Uhm Jae-Sun , Joung Boyoung , Lee Moon-Hyoung , Pak Hui-Nam 

TITLE=Extra-Pulmonary Vein Triggers at de novo and the Repeat Atrial Fibrillation Catheter Ablation

JOURNAL=Frontiers in Cardiovascular Medicine

VOLUME=8

YEAR=2021

URL=https://www.frontiersin.org/journals/cardiovascular-medicine/articles/10.3389/fcvm.2021.759967

DOI=10.3389/fcvm.2021.759967

ISSN=2297-055X

ABSTRACT=<p><bold>Background:</bold> Extra-pulmonary vein triggers can play a significant role in atrial fibrillation recurrence after catheter ablation. We explored the characteristics of the extra-pulmonary vein (PV) triggers in <italic>de novo</italic> and repeat atrial fibrillation (AF) catheter ablation (AFCA).</p><p><bold>Methods:</bold> We included 2,118 patients who underwent a <italic>de novo</italic> AFCA (women 27.6%, 59.2 ± 10.9 years old, paroxysmal AF 65.9%) and 227 of them conducted repeat procedures. All included patients underwent isoproterenol provocation tests at the end of the procedure, and then we analyzed extra-PV triggers-related factors.</p><p><bold>Results:</bold> Extra-PV triggers were documented in 11.7% of patients undergoing <italic>de novo</italic> AFCA (1.22 ± 0.46 foci per patient) and 28.6% undergoing repeat AFCA (1.49 ± 0.73 foci per patient). Older age and higher LA volume index in <italic>de novo</italic> procedures and women, diabetes, and higher parasympathetic nerve activity (heart rate variability) in repeat-AFCA were independently associated with the existence of extra-PV triggers. The septum (19.9%), coronary sinus (14.7%), and superior vena cava (11.2%) were common extra-PV foci. Among 46 patients who were newly found to have mappable extra-PV triggers upon repeat procedures, 15 (32.6%) matched with the previous focal or empirical extra-PV ablation sites. The rate of AF recurrence was significantly higher in patients with extra-PV triggers than in those without after <italic>de novo</italic> (HR 1.91, 95% CI 1.54–2.38, <italic>p</italic> &lt; 0.001) and repeat procedures (HR 2.68, 95% CI 1.63–4.42, <italic>p</italic> &lt; 0.001).</p><p><bold>Conclusions:</bold> Extra-PV triggers were commonly found in AF patients with significant remodeling and previous empirical extra-PV ablation. The existence of extra-PV triggers was independently associated with poorer rhythm outcomes after the <italic>de novo</italic> and repeat AFCA.</p>