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patterns could be the variation in the distribution of the atrial musculature extensions from the LA into the PVs. When both the superior and inferior PVs were eliminated simultaneously, the ablation results were best. This finding was observed in relatively several cases in the middle of the ablation procedure for AF, and many investigators have recognized the various patterns of the disappearance of the PV electrograms during PVI. However, this study is the first to investigate its relationship to the clinical long-term results of the ablation treatment in a sophisticated fashion. The authors of the present study did not perform a confirmation of the elimination of the dormant conduction between the PVs and LA by injecting adenosine after PVI, which might have had an influence on the reconnections of the PVs.9 If a sufficient amount of RF energy was delivered at the presumably dormant conduction area, the impact of the present study may have been outweighed. Additional RF applications in the carina region were required for successful PVI, even though a complete continuous isolation lesion line formation was achieved in the antral area of the LA.10 In addition, failure to electrically isolate the PV carina is significantly associated with AF recurrence.11 As the authors describe, the Marshall vein may exert arrhythmogenic effects in terms of provoking AF episodes by connecting the LA and PVs as epicardial conduit tissue.12 The authors describe the encircling isolation line as neither continuous nor transmural; however, the Marshall ligament could contribute to an epicardial electrical connection between the LA and PVs that could not be obtained with successful transmural ablation of the LA wall. Additional RF applications in the carina region might abolish all the electrical connections associated with the Marshall ligament conduit tissue.13 When bidirectional electrical disconnection is obtained, which is ascertained by pacing inside and outside the encircling line at the antrum, we can be sure that successful PVI has been accomplished. However, pacing in the carina region is also an important diagnostic method of investigating whether complete PVI has been achieved or not. In such cases, there is no electrical connection between the PVs and Marshall ligament that could result in a false electrical isolation of the PVs from the LA. Kasai et al already demonstrated the presence of electrical connections between the distal CS musculature and LA myocardium, which may provide anatomic pathways or a substrate trial fibrillation (AF) remains the most common sustained cardiac arrhythmia and continues to be a major cause of strokes and hospitalizations worldwide. Since its inception in the 1990 s, catheter ablation of AF has become a continuously evolving therapeutic procedure. Many institutions have spent considerable efforts in defining the optimal ablation strategies for the elimination of paroxysmal and nonparoxysmal AF. Pulmonary vein isolation (PVI) has quickly become a cornerstone of catheter ablation of AF.1,2 It was first performed as an ostial ablation, but, because of the risk of PV stenosis and recognition of vital antral drivers, the antral PVI strategy evolved. However, enthusiasm has been dampened by the high frequency of PV reconnections, resulting in recurrent AF.3,4 The quest for permanent PVI has resulted in the development of numerous technologies and tools, such as irrigation and deflectable sheaths for improving stability, and contact sensing systems. Despite these advances, recurrence rates during long-term follow-up after a single ablation procedure for paroxysmal AF remain unacceptably high at approximately 20– 30%, with even higher rates of recurrence for persistent AF.5

Analysis of the Anatomical Variation of the Atrial Musculature May Predict the Success of Pulmonary Electrical Isolation