Pulmonary vein atrial tachycardia: do we really need to isolate or freeze?

Excerpt

Focal atrial tachycardias (ATs) have been demonstrated to arise from several anatomic sites in both atria and annexing structures that can be accurately predicted by established P wave morphology algorithms with high sensitivity and specificity [1‐9]. Pulmonary vein (PV) ATs account for the majority of left-sided focal ATs with a propensity for the ostium of a single PV, especially the superior PVs [6, 10, 11]. Patients with focal PV ATs are distinct to those with atrial fibrillation (AF) as they are usually younger, with normal sized left atria and paucity of traditional AF risk factors [7, 12]. The arrhythmic mechanism underlying PV ATs is understood to be due to triggered activity or abnormal automaticity whereby the tachycardia cycle length is usually longer than those with AF, who have diffuse atrial remodelling and a spectrum of other re-entrant arrhythmias [7, 13]. Further, in those with AF, the tachycardia foci are often seen in multiple PVs and deeper into the veins, warranting isolation of all four PVs [7]. By contrast, focal ablation strategy in patients with PV ATs has demonstrated excellent long-term success rates with no AF seen at more than 7 years of follow-up [14]. Alternative ablation approach of targeted pulmonary vein isolation (PVI) has also been performed, with a small retrospective series (n = 26 patients) demonstrating potential superiority to focal ablation [10]. However, in the absence of prospective randomised data, the work by Wei and co-workers in this issue of the Journal represents a welcome addition to the literature. [15] …