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Pulmonary veins (PVs) are the predominant sources of paroxysmal atrial fibrillation (AF), and electrical PV isolation has become an established interventional treatment for patients suffering from AF. There are a few cases describing PV tachycardias; however, mechanisms of PV arrhythmogenicity resulting in PV tachycardias remain incompletely understood. We report on a patient who underwent PV isolation for paroxysmal AF, in whom a persistent PV tachycardia was observed within an isolated vein. This tachycardia was stable in nature and different pacing manoeuvres revealed electrophysiological features consistent with reentry (Lasso displaying the entire tachycardia cycle length, concealed entrainment, overdrive termination, and induction by programmed stimulation) as the underlying mechanism.

Aims To investigate the effectiveness of additional substrate modification (SM) by left atrial (LA) linear lesions as compared with pulmonary vein isolation (PVI) alone in patients with persistent atrial fibrilla- tion (AF) in a prospective randomized study. Percutaneous PVI has evolved as an accepted treatment for paroxysmal AF but seemed to be less effective in patients with persistent AF. The benefit of PVI alone and additional linear lesions has not been validated in a randomized study so far. Methods and results Sixty-two patients with persistent AF (median duration 7, range 1-18 months) were randomly assigned to either PVI alone (n ¼ 30) or additional SM (n ¼ 32) consisting of a roof line connecting both left superior and right superior PV and LA isthmus ablation between left inferior PV and mitral annulus. Procedures including SM were performed using a three-dimensional mapping system (EnSite NavX TM , St Jude Medical, St Paul, MN, USA). Anti-arrhythmic drugs were discontinued within 8 weeks after ablation in both groups. Follow-up included daily trans-telephonic ECG transmitted irrespective of the patient's symptoms. PVI was successful in 98% of all targeted veins in both groups. Additional SM did not increase fluoroscopy time (72.1+ 18.7 vs. 72.9+ 17.3 min, P ¼ 0.92) because of the use of three-dimensional navigation in the PVI þ SM group. AF recurrences within the first 4 weeks following ablation were more common after PVI alone (77%) than additional SM (44%, P ¼ 0.002). After a follow-up time of 487 (429-570) days, only 20% of patients undergoing stand alone PVI remained in sinus rhythm when compared with 69% following PVI combined with SM (P ¼ 0.0001). Two patients assigned to PVI þ SM experienced procedure-related complications (cardiac tamponade and minor stroke) which resolved without sequelae. Conclusion PVI alone is insufficient in the treatment of persistent AF. However, additional left linear lesions increase the success rate significantly. Early AF-relapses are associated with a negative outcome after PVI alone but not following additional SM.