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=Volume 8 - 2021

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=Background: Extra-pulmonary vein (PV) triggers can play a significant role in atrial fibrillation (AF) recurrence after catheter ablation. We explored the characteristics of extra-PV triggers in de novo and repeat AF catheter ablation (AFCA). 
Methods: We included 2,118 patients who underwent a de novo AFCA (female 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 we analyzed extra-PV triggers-related factors.
Results: Extra-PV triggers were documented in 11.7% of patients undergoing de novo 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 de novo 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 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 de novo (HR 1.91, 95% confidence interval [CI] 1.54-2.38, p<0.001) and repeat procedures (HR 2.68, 95% CI 1.63-4.42, p<0.001). 
Conclusions: 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 de novo and repeat AFCA.