Case report of persistent atrial fibrillation with durably isolated PVs: What’s next?

Abstract

Pulmonary vein isolation (PVI) has emerged as a safe and effective treatment for patients with paroxysmal and persistent atrial fibrillation. Nevertheless, in some patients a relapse of atrial fibrillation occurs although pulmonary veins are durably isolated. For those patients the underlying mechanisms of atrial fibrillation perpetuation are manifold and optimal treatment options are not yet defined. We describe a case of a 55-year-old man with a history of atrial fibrillation and previous PVI presenting with persistent AF and arrhythmia induced cardiomyopathy. During the redo procedure electro-anatomical mapping revealed durably isolated PV. Bipolar mapping showed large low-voltage areas at the posterior wall and the septum. As the patient was refractory to electrical cardioversion it was decided to modify the large low-voltage areas as potential arrhythmic substrate. After performing additional ablation with isolation of the posterior wall and two anterior/septal lines the patient spontaneously converted to sinus rhythm. Ablation in patients with persistent AF despite durable PVI remains a challenge for the treating team. Individualized ablation approaches addressing additional arrhythmic substrates or extra PV triggers can be considered to treat patients with persistent AF and durable PVI.