Pulmonary vein internal electrical activity does not contribute to the maintenance of atrial fibrillation

Whether the electrical activity generated in the pulmonary veins (PVs) during atrial fibrillation (AF) contributes to the maintenance of arrhythmia is not known. The study population consisted of 22 patients (mean age 58 ± 9.5 years, 16 men) with persistent (12 patients) or intermittent (10 patients) AF. Mapping of the left atrium (LA) was performed with a 64-electrode basket catheter. PVs were mapped simultaneously with the LA with a quadripolar catheter. PV were defined as arrhythmogenic (if frequent ectopic activity induced AF) or nonarrhythmogenic (if no ectopic activity was observed during the procedure). AF cycle lengths in arrhythmogenic and nonarrhythmogenic PV were 130 ± 50 ms and 152 ± 42 ms, respectively (P < 0.001). Both were significantly longer than simultaneous AF activity recorded from the posterior wall of the LA (116 ± 49 ms, P < 0.001). AF cycle lengths in arrhythmogenic PVs as compared to nonarrhythmogenic PVs were: right superior PV 125 ± 49 ms versus 148 ± 51 ms; left superior PV 140 ± 52 ms versus 161 ± 30 ms; left inferior PV 127 ± 48 ms versus 147 ± 45 ms; and right inferior PV 129 ± 38 versus 152 ± 44 ms (P < 0.001 for all four comparisons). AF activity in the PV was more organized than in the posterior wall of the LA and the veins were activated in a proximal-to-distal direction during sustained AF episodes. In patients with AF not related to rheumatic heart disease, the posterior wall of the LA has faster activity than the PVs. The AF activity generated inside the PV during sustained AF episodes originates from the posterior wall of the LA rather than from focal firing.