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The electrocardiogram of a 14-year-old boy with recurrent palpitation showed a wide QRS regular tachycardia with a right bundle branch block and right-axis deviation of 226 beats per minute. Verapamil infusion terminated the tachycardia after a few minutes. Electrophysiological study revealed that this tachycardia was considered as a reentrant tachycardia associated with the anterograde left posterior accessory pathway (AP) and retrograde right septal AP. Radiofrequency application was performed and eliminated both APs, and there was no recurrence of wide QRS tachycardia.

Background Even with the use of a reduced energy setting (20–25W), excessive transmural injury (ETI) following catheter ablation of atrial fibrillation (AF) is reported to develop in 10% of patients. However, the incidence of ETI depends on the pulmonary vein isolation (PVI) method and its esophageal temperature monitor setting. Data comparing the incidence of ETI following AF ablation with and without esophageal temperature monitoring (ETM) are still lacking. Methods This study was comprised of 160 patients with AF (54% paroxysmal, mean: 24.0±2.9kg/m 2 ). Eighty patients underwent ablation accompanied by ETM. The primary endpoint was defined as the occurrence of ETI assessed by endoscopy within 5d after the AF ablation. The secondary endpoint was defined as AF recurrence after a single procedure. If the esophageal temperature probe registered >39°C, the radiofrequency (RF) application was stopped immediately. RF applications could be performed in a point-by-point manner for a maximum of 20s and 20W. ETI was defined as any injury that resulted from AF ablation, including esophageal injury or periesophageal nerve injury (peri-ENI). Results The incidence of esophageal injury was significantly lower in patients whose AF ablation included ETM compared with patients without ETM (0 [0%] vs. 6 [7.5%], p =0.028), but not the incidence of peri-ENI (2 [2.5%] vs. 3 [3.8%], p =1.0). AF recurrence 12 months after the procedure was similar between the groups (20 [25%] in the ETM group vs. 19 [24%] in the non-ETM group, p =1.00). Conclusions Catheter ablation using ETM may reduce the incidence of esophageal injury without increasing the incidence of AF recurrence but not the incidence of peri-ENI.

Background: We reviewed the effectiveness and safety of cardiac resynchronization therapy (CRT) for patients with New York Heart Association (NYHA) class IV non-ambulatory heart failure (NAHF). Methods: From 2006 to 2011, 310 patients underwent CRT at Kobe University Hospital and Himeji Cardiovascular Center because of heart failure. Of these, 29 NAHF patients were retrospectively analyzed. The control group comprised 21 age- and ejection fraction-matched patients with NAHF who did not undergo CRT from the ICU database of Kobe University Hospital. The primary endpoint was all-cause death and hospitalization for heart failure. Response was defined as a >15% reduction in left ventricular end-systolic volume (LVESV). Results: CRT was performed successfully without serious complications in all patients. Twenty-three patients (79%) were discharged 19±15 days after CRT implantation, while 6 (21%) died during their hospital stay due to progressive heart failure. Compared with the control group, patients in the CRT group showed significant improvements in the primary endpoint (log-rank p=0.04). Six patients (21%) were defined as responders and the Kaplan–Meier curve showed that responders experienced a better outcome than non-responders (log-rank p=0.029). LV dyssynchrony before implantation was significantly related to the occurrence of the primary endpoint (p=0.02). Conclusions: CRT can be safely used in patients with NAHF and can improve long-term patient outcomes, especially in treatment responders.

Background: Esophageal injury following catheter ablation of atrial fibrillation (AF) is reported to occur in 35% of patients. Even with a low energy setting (20–25 W), lesions develop in 10% of patients. Body mass index (BMI) has been reported to be a predictor of esophageal injury, indicating that patients with a low BMI (39 °C, radiofrequency (RF) application was stopped immediately. RF application could be performed in a “point by point” manner for a maximum of 20 s. Endoscopy was performed 1–5 days after ablation. Results: Esophageal mucosal injury was not observed in any patient in the study. Conclusions: Catheter ablation using ETM reduced the incidence of esophageal injuries, even in patients with a low BMI.

BACKGROUND The incidence of hematoma formation following implantation of a cardiovascular implantable electronic device (CIED) is estimated to be 5% even if a pressure dressing is applied. It is unclear whether a pressure dressing can really compress the pocket in different positions. Furthermore, the adhesive tape for fixing pressure dressings can tear the skin. We developed a new compression tool for preventing hematomas and skin erosions. METHODS AND RESULTS We divided 46 consecutive patients receiving anticoagulation therapy who underwent CIED implantation into 2 groups (Group I: conventional pressure dressing, Group II: new compression tool). The pressure on the pocket was measured in both the supine and standing positions. The incidence of hematomas was compared between the 2 groups. The pressure differed between the supine and standing positions in Group I, but not in Group II (Group I: 14.8±7.1 mmHg vs. 11.3±9.9 mmHg, P=0.013; Group II: 13.5±2.8 mmHg vs. 13.5±3.5 mmHg, P=0.99). The incidence of hematomas and skin erosions was documented in 2 (8.7%) and 3 (13%) Group I patients, respectively. No complications were documented in Group II. CONCLUSIONS The new compression tool can provide adequate continuous pressure on the pocket, regardless of body position. This device may reduce the incidence of hematomas and skin erosions after CIED implantation.

Background: The efficacy of epicardial catheter ablation for ventricular tachycardia has been reported. However, the safest anatomical method for pericardial puncture has not been determined. Methods: Thirty patients who underwent 3-dimensional computed tomography (3D-CT) preceding catheter ablations for atrial fibrillation were enrolled in this study. We used the skin surface 1 cm below the xiphisternum as the puncture site. For the anterior approach, the attainment site was the pericardium of the mid portion of right ventricular anterior site, and for the posterior approach it was the pericardium of the inferior ventricular site. The distance and the angle between the 2 sites were measured using 3D-CT. Results: For the anterior approach, the distance was 54±11 mm and the needle angle was 37±11° toward the left scapula and 34±12° towards the back of the body. For the posterior approach, the distance was 56±10 mm and the corresponding needle angles were 60±9° and 86±13°. The distance correlated with BMI for the anterior and posterior approaches (anterior approach: r2=0.43, P

We report a case of Ebstein׳s anomaly in which radiofrequency catheter ablation of an accessory pathway was successfully performed under intra-cardiac echocardiography. A 50-year-old woman was referred to our hospital for radiofrequency catheter ablation of a paroxysmal supraventricular tachycardia. A 12-lead surface electrocardiogram revealed ventricular pre-excitation associated with type B Wolff–Parkinson–White syndrome. In the baseline electrophysiological study, an orthodromic atrioventricular reciprocating tachycardia with a right posterior accessory pathway was induced. A phased-array intra-cardiac echo probe was positioned in the right atrium to visualize the atrioventricular junction. The key structures for catheter ablation, such as the atrialized right ventricle, atrioventricular junction, and tricuspid valve, were clearly visualized on intra-cardiac echocardiography. Radiofrequency current was successfully delivered at the atrioventricular junction, where a Kent potential was recorded. During a 6-month follow-up period, the patient was free from arrhythmias. The findings in this case suggest that phased-array intra-cardiac echocardiography is useful for ablation of right-sided accessory pathways in patients with Ebstein׳s anomaly.

Essential thrombocythemia (ET) has been reported to cause acute coronary disease. However, the efficacy of anti-platelet therapy for ET is unclear since there are individual differences in the platelet function of ET patients. Here we report a case of a 62-year-old man with ET who was admitted to our hospital because of acute coronary syndrome. He underwent coronary angioplasty. Dual anti-platelet therapy with aspirin (81mg/day) and clopidogrel (75mg/day) was subsequently initiated. We evaluated platelet reactivity in P2Y12 reaction units, and subsequently determined anti-platelet drugs and corresponding doses.

Functional Block in the Posterior Right Atrium. Introduction: Conduction block in the posterior right atrium (RA) plays an important role in perpetuating atrial flutter (AFL). Although conduction blocks have functional properties, it is not clear how the block line changes with the pacing rate, pacing site, and administration of antiarrhythmic drugs. Methods and Results: Forty patients with typical AFL were enrolled. Pacing (110, 170, 230 ppm) from the coronary sinus ostium (CSo) and low lateral RA was performed. After 1 mg/kg pilsicainide (pure sodium channel blockade) administration, the pacing protocol was repeated. Conduction block was assessed based on a color-coded isopotential map and 20 points of virtual unipolar electrograms in the posterior RA using noncontact mapping. Block line proportion was defined as the percentage of length of the block line between the superior and inferior vena cava. The pacing rate-dependent extension of the block proportion was significant during pacing from both sides (pacing from the CSo: 59 ± 17% at 110 ppm, 69 ± 16% at 230 ppm, P < 0.05; pacing from the low lateral RA: 43 ± 19% at 110 ppm, 55 ± 22% at 230 ppm, P < 0.05). The block line was significantly longer during CSo pacing than during low lateral RA pacing at each rate (all P < 0.05). After pilsicainide administration, the block line extended further. Conclusion: In addition to pacing rate-dependent and site-dependent changes in the block line, pilsicainide further extended the block line length. This phenomenon explains the clinical observation that counterclockwise AFL occurs more frequently than clockwise AFL, and the mechanism of class IC AFL. (J Cardiovasc Electrophysiol, Vol. 23, pp. 827-834, August 2012)

SummaryWe describe a case of a 60-year-old male with dilated phase of hypertrophic cardiomyopathy caused by Fabry disease. He was diagnosed to have a cardiac variant of Fabry disease by an enzyme assay and a right ventricular endomyocardial biopsy which revealed specific features of this disease and cardiac involvement was the sole manifestation. He has developed dilated cardiomyopathy with sustained atrial flutter and frequent non-sustained ventricular tachycardia requiring isthmus ablation and cardiac resynchronization therapy with defibrillator.

Background The optimal left ventricle (LV) pacing site for cardiac resynchronization therapy (CRT) has been investigated, but less is known about the optimal site in the right ventricle (RV). The present study examined whether electrical resynchronization guided by electroanatomical mapping (CARTO) results in mechanical resynchronization. Methods and Results The study group included 13 patients indicated for CRT: 10 with nonischemic cardiomyopathy, 2 with ischemic cardiomyopathy and 1 with cardiac sarcoidosis, (mean LV ejection fraction: 32±10%). CARTO of the RV septum was performed to identify the site with the most delayed conduction time during LV pacing. Hemodynamic measurements were performed during conventional biventricular pacing with the RV apex and LV (C-BVP) and during biventricular pacing with the most delayed site of the RV (d-RV) and LV (D-BVP). Lead placement at 15 coronary sinus veins was examined in the 13 patients. During pacing from anterolateral veins (n=2), the d-RV was the RV apex (RVA) in 1 patient and the mid-septum in the other. During pacing from lateral veins (n=9), the d-RV comprised the RVA (n=3), the mid-septum (n=5), and the right ventricular outflow tract (RVOT) (n=1). During pacing from the posterolateral veins (n=3), the d-RV was the RVOT in all cases. In 11 of 15 sites, d-RV differed from conventional RVA. Compared with C-BVP, D-BVP produced a significant improvement in LV dp/dt. Furthermore, RV mid-septum and LV pacing markedly increased LV dp/dt and pulse pressure (PP), but RVOT and LV pacing did not. D-BVP vs C-BVP: %LV dp/dt 30±20 and 15±15%, p

Mitral annular calcification (MAC) is frequently observed, but it rarely causes left ventricular outflow tract (LVOT) obstruction (LVOTO). An 83-year-old woman with hypertension, diabetes, and dyslipidemia was admitted to our hospital because of exertional dyspnea. She was diagnosed with hypertensive heart disease. Her symptoms were exacerbated by exertion, and she had no symptoms at rest. Transthoracic echocardiography showed massive posterior MAC, a sigmoid septum, and LVOTO, with a peak gradient of 15.4mmHg at rest. Systolic anterior motion of the anterior mitral leaflet was not found. Moreover, the LVOT gradient in the stress condition was evaluated, and an increased LVOT gradient (47.3mmHg) and chest discomfort was noted after 20μg/kg/min of dobutamine was administered and the Valsalva maneuver was used. Hence, the patient was diagnosed with latent LVOTO. Interestingly, the distance between the septal wall, which was protruding into the left ventricular cavity, and the mitral valve coaptation, which was pushed up by the posterior MAC, had become closer, causing dynamic LVOTO. Since it is difficult to treat LVOTO with medication, ultimately, septal myectomy and mitral valve replacement were performed, which improved her symptoms. Evaluating the LVOT pressure gradient in stress condition is important in patients with MAC. Learning objective: Mitral annular calcification (MAC) is commonly found in older people. However, it is not well known that MAC can cause left ventricular outflow tract obstruction (LVOTO). In the present case, massive posterior MAC was one of the factors that caused LVOTO. Left ventricular hypercontractility and a sigmoid septum were found to contribute to LVOTO, and stress echocardiography was useful for detecting the latent LVOTO. It is interesting that MAC can contribute to LVOTO in a stress condition.>

A 65-year-old man was referred to our hospital with persistent atrial fibrillation (AF). Before the ablation procedure, 3-dimensional computed tomography revealed a left atrial anomalous muscular band connecting the posterior side of the left atrial roof and the right edge of the fossa ovalis. During the first ablation procedure, the band interfered with the manipulation of the catheter, resulting in only the left pulmonary vein (PV) being isolated. However, AF recurred. During the second procedure, careful catheter manipulation permitted complete right PV isolation, after which, the patient has not had AF recurrence for more than 3 years.

Background: The upper lim it of vulnerability (UL V) closely correlates with the defibrillation threshold (OFT) . The aim of th is study was to establish the optimal protocol for using the UL V test to predict high OFT (>20 J) without inducing ventricular fibrillation (VF) . Methods and Results: The 10-J and 15-J ULV test with 3 coupling intervals (-20, 0, and +20ms to the peak of T-wave) and the OFT test were performed in 96 patients receiving implantable cardioverter defibrillator. ULV ::; 10J was confirmed in 47 (49%). ULV ::; 15J was confirmed in 70 (77%) of 91 patients (15-J ULV test could not be done in 5). The sensitivity and negative predictive value of both ULV > 1 OJ and> 15J for predicting high OFT were 100%. The specificity and positive predictive value of ULV > 15 J were higher than those for ULV > 1 OJ (85% vs. 55%, 43% vs. 22%, respectively). The rate of VF inducibility for confirming ULV ::; 15J was lower than that for ULV ::; 10J (23% vs. 51 %, P

Slow pathway (SP) ablation of atrioventricular (AV) nodal reentrant tachycardia (AVNRT) can be complicated by unexpected AV block even at sites10 mm inferior to the bundle of His (HB), and one cause is thought to be the inferior dislocation of an antegrade fast pathway (A-FP). We assessed locations of FPs guided by CARTO.Sites of FPs were mapped guided by CARTO before SP ablation in 18 patients with slow-fast AVNRT. The A-FP was defined as the site with the minimum interval between the stimulus and HB potential when pace mapping in the right atrial septum.The A-FP was 7.9 ± 7.5 mm inferior and 2.9 ± 5.0 mm posterior to the HB. In 6 of 18 patients (33%), the A-FP was inferiorly dislocated10 mm to the HB. SP ablation was successfully performed in all patients at sites10 mm from both the HB and the A-FP without AV block. In the inferiorly dislocated A-FP group, A-FPs seemed to be positioned much more on atrial sites and sufficiently posterior to SP ablation sites.The A-FP inferiorly dislocated10 mm to the HB in one third of patients with AVNRT and seemed to be positioned deep on atrial sites. It is again emphasized that SP ablation within the triangle of Koch should be performed at a very ventricular annulus site, particularly in the inferiorly dislocated A-FP group.

Background: The posteromedial right atrium (PMRA) forms a block line during typical atrial flutter (AFL). However, whether upper turnover portion exists at the anterior or posterior superior vena cava (SVC) has not been determined. Methods: We performed right atrial mapping during AFL in 20 patients (typical AFL, n = 17; reverse typical AFL, n = 3) using an electroanatomical mapping system. Results: Mean AFL cycle length was 224 ± 20 ms and mean number of mapping points was 140 ± 27. PMRA formed a block line during both typical and reverse AFL in all patients. However, in 16 of 17 patients mapped with typical AFL, PMRA did not extend superiorly to the orifice of the SVC and AFL wave propagated between the upper limit of the PMRA and the posterior SVC. In the remaining patient mapped with typical AFL, a double potential was recorded along the PMRA continuously between the orifices of the inferior vena cava (IVC) and SVC. In the three patients mapped with reverse typical AFL, a posterior barrier was detected from IVC to the upper limit of the PMRA and AFL wave propagated between the upper limit of the PMRA and the posterior SVC. Mean length from IVC to upper limit of the PMRA was 81 ± 8% of the length from IVC to SVC. Conclusions: PMRA forms a functional block line during both typical and reverse typical AFL. The upper turnover portion of reentry circuit for AFL was observed between the upper limit of the PMRA and the posterior SVC in the majority of isthmus-dependent AFL patients.

We investigated the differences in the endocardial substrates between ischemic cardiomyopathy (ICM) and non-ICM (NICM) by using electro-anatomical mapping and pace-mapping. We studied 18 patients (ICM and NICM, 9 each) with monomorphic ventricular tachycardia (VT) documented by 12-leads ECG. Low voltage area was defined by signal amplitude1.5 mV. A pace-map QRS morphology that matched VT in10 of the 12-leads ECG was regarded as a pace-map match. And conduction delay during pace-mapping was defined as the stimulus to QRS intervalor=40 ms. Low voltage area was 53.8 +/- 21.5 and 20.8 +/- 16.7 cm2 in ICM and NICM patients, respectively (P = 0.002). Pace-mapping was assessed in 6 ICM and 9 NICM. Pace-map match with conduction delay were obtained in all the 6 ICM patients. But in NICM patients, pace-map match with conduction delay was obtained in 3 patients. Pace-map match sites where conduction delay was not observed were obtained in 5 patients. Pace-map match could not be obtained in 1 patient. We attempted ablation in 6 ICM and 7 NICM patients. Subsequently, VT recurrence was not observed in ICM but it was observed in 6 of 7 NICM patients (log-rank P = 0.0016). In NICM patients, the arrhythmogenic substrate that represented the abnormal electrogram and conduction delay was observed less within the endocardial surface when compared with that observed in ICM. VT recurrence rate subsequent to endocardial ablation was higher in NICM than in ICM patients.

Nitric oxide (NO) generation in the rat gastric mucosa during ischemia-reperfusion was measured using an NO-sensitive electrode. Under pentobarbital sodium anesthesia, an electrode was inserted into the submucosa from the serous membrane side in the fundus. After steady-state baseline recording, the celiac artery was clamped for 30 min, and then ischemia-reperfusion was achieved by removing the clamp. The clamping of the celiac artery caused a decrease in blood flow and an increase in NO level in the gastric tissue. Just after the removal of the clamp, the NO level rapidly fell and returned to the baseline level. Administration of N G-nitro-l-arginine methyl ester (an NO synthase inhibitor, 30 mg/kg ip) before ischemia significantly attenuated both the increase in NO level during ischemia and the formation of acute gastric mucosal lesions observed after 60 min reperfusion. Administration of superoxide dismutase (a superoxide radical scavenger, 10,000 U/kg iv) at the end of ischemia inhibited both the rapid decrease in NO level during the reperfusion and the gastric mucosal erosions. Because NO and superoxide radical produce a highly reactive peroxynitrite, it can be argued that NO has an important pathological role in acute gastric mucosal injury induced by ischemia-reperfusion. Our conclusion was strongly supported by immunohistochemical staining of nitrotyrosine residues, an indication of peroxynitrite formation.

Background: Long-term efficacy of right ventricular apex (RVA) pacing has not been well known. Methods and Results: In consecutive 111 patients who implanted new DDD-pacemaker between Jan. 2000 and Dec. 2002, we studied 20 patients (69± years) with sick sinus syndrome (SSS) and 28 patients (65±14 years) with atrioventricular block (AVB) who could be followed until first generator replacement (77±17 months after pacemaker implantation). Follow-up was continued after the generator replacement. All RV leads were implanted at RVA. Cardiac function evaluated by 2-dimensional echocardiography at the generator replacement and clinical event during the follow-up period were compared between both groups. Cumulative percentage of RVA pacing was higher in AVB group than in SSS group (90±27 versus 44±42%, P

Background: Cardiac resynchronization therapy (CRT) showed complete recovery of cardiac function in some patients with idiopathic dilated cardiomyopathy (DCM).Objective: To clarify the incidence, clinical characteristics and prognosis of these patients.Methods: Consecutive 44 patients (67±10 years, 29 males) with severe heart failure diagnosed as DCM, left ventricular ejection fraction (LVEF) 120 ms who underwent CRT excluding previously device implanted cases were studied. We compared clinical characteristics and long term (37±10 months) prognosis among patients with hyperresponders (LVEF>50%), responders (>5% improvement of LVEF but

However, CRT has failed to improve the New York Heart Association (NYHA) class in up to 30% of patients and 1 reason for this may be the position of the implanted lead. 4 Several studies have focused on a comparison of the hemodynamic effects of stimulation sites located at different coronary vein tributaries. In those studies, the optimal pacing site in the left ventricle (LV) was shown to be the LV free wall, which is the most delayed area. 5 However, because of anatomical and technical limitations, up to one-third of patients may not have the LV lead implanted at a site in the LV free wall. In contrast, an electrode implanted in the right ventricle (RV) is much easier to relocate, but less is

(tetrapolar, 2-5-2 mm electrode spacing). Pacing was attempted from the distal electrode pair of the ablation catheter at the lowest pacing intensity that captured. The first PPI recorded from the distal electrode pair (PPIDist) of the ablation catheter was compared with that recorded from the proximal electrode pair (PPI-Prox) of the ablation catheter, the first PPI of the RVA (PPI-RVA) (corrected by subtracting the difference in activation time between the distal pair and the RVA), and the second PPI (PPI-2) recorded from the distal electrode pair of the ablation catheter (corrected by subtracting the tachycardia cycle length). Results: The analysis of PPI-Dist was not possible in 12 ablation sites due to pacing artefact. A significant and high correlation was found between the PPI-Dist and the PPI-Prox (R=0.88; P 20ms between the PPI-Dist and the PPI-Prox, the PPI-AVD, and the PPI-2 were found in 11 ablation sites. Conclusions: The PPI can be accurately estimated by the PPI-2. A less reliable estimation of the PPI-Dist can be obtained by the PPI-Prox and the PPI-AVD.

Background Noncontact mapping is useful for the diagnosis of various arrhythmias. Virtual unipolar electrogram morphologies (VUEM) of the conduction block and the turnaround points, however, are not well defined. We compared the VUEM characteristics of a transverse conduction block in the posterior right atrium (RA) with those of contact bipolar electrograms obtained during typical atrial flutter (AFL). Methods Contact bipolar electrograms were used to map the posterior RA during typical AFL in 16 patients. Twenty points of the VUEM recorded along the block line were analyzed and compared with contact bipolar electrograms. Results Seventeen AFLs were analyzed. Fifteen AFLs showed an incomplete transverse conduction block in the posterior RA by contact bipolar mapping. A double potential on the block line corresponded to the two components of the VUEM, in which the second component showed an Rs, RS, or rS pattern. At the turnaround point, a fused double potential of the contact bipolar electrograms corresponded to a change of the second component of the VUEM from an rS to a QS morphology. Two AFLs showed a complete block line in the posterior RA. The contact bipolar electrogram showed double potentials from the inferior vena cava to the superior vena cava, whereas the second component of the VUEM remained in an unchanged Rs, RS, or rS pattern. Conclusion VUEM analysis was a reliable method for identifying the posterior block line during AFL. This method may also be applicable for detecting block lines and turnaround points of circuits in other unmappable arrhythmias.

Background: Catheter ablation (CA) is an established therapy for atrial fibrillation (AF). However, the assessment of anatomical information and predictors of AF recurrence remain unclear. We investigated the relationship between anatomical information on the left atrium (LA) and pulmonary veins (PVs) from three-dimensional computed tomography images and the recurrence of AF after CA. Methods: Sixty-seven consecutive AF patients (mean age: 62±10 years, median AF history: 42 (12; 60) months, mean LA size: 41±7 mm, paroxysmal: 56%) underwent CA and were followed for 19±10 months. The segmented surface areas (antral, posterior, septal, and lateral) and dimensions (between the anterior and posterior walls, the right inferior PV and mitral annulus [MA], the right superior PV and MA, the left superior PV and MA, and the mitral isthmus) of the LA were evaluated three dimensionally using the NavX system. The cross-sectional areas of the PVs were also evaluated. Results: After the follow-up period, 49 patients (73%) remained free from AF. A multivariate analysis showed that the diameter of the mitral isthmus and cross-sectional area of the right upper PV were associated with AF recurrence (odds ratio: 1.070, CI: 1.02–1.12, p=0.001; odds ratio: 0.41, CI: 0.21–0.77, p=0.006). Conclusion: Enlargement of the mitral isthmus and a smaller right superior PV cross-sectional area were associated with AF recurrence.