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Maintenance of sinus rhythm by catheter-based ablation of atrial fibrillation (AF) has become a common strategy for symptom control. The cornerstone of AF ablation is pulmonary vein isolation (PVI) with both entrance and exit block. Wide area circumferential ablation (WACA) in the antrum has increasingly replaced pulmonary vein (PV) ostial ablation because of a higher success rate and reduced risk of PV stenosis.1 However, a percentage of patients require a second procedure for AF control.2,3 At repeat ablation, PV reconnection is a common finding, and occasionally, it is difficult to achieve true entrance and exit block, especially for the right pulmonary veins (RPVs).Editor’s Perspective see p 1268When faced with difficulty in obtaining RPV isolation, we follow a stepwise approach (Figure 1) to successfully identify the area of persistent connection. If WACA fails to achieve RPV entrance and exit block, some alternatives include (1) ablation more ostially and into the carina region, which potentially risks PV stenosis; (2) wider encirclement, which requires a larger ablation region and more radiofrequency application, and may be unsuccessful as a result of anatomic factors (in many cases because of the presence of the phrenic nerve in the septal aspect of the RPVs); or (3) mapping the activation pattern of the persistent connection. Voltage mapping can demonstrate the extent of prior ablation lesions and can also document lesion maturity at the interface of healthy tissue and scar. Activation mapping during pacing from the reconnected PV can reveal the connection pathways, which could be either via the left atrium (gaps in the line of WACA ablation) or connection to adjacent structures (RPV to right atrium). During pacing, if the earliest signal is on the left atrial side of the WACA line, there is a gap in the line, which should be …

Electroanatomic Mapping of the Intercaval Bundle in Atrial Fibrillation