Ablation of Nonpulmonary Vein Triggers

Nonpulmonary vein (non-PV) “triggers” can be identified in 10% to 33% of unselected patients with atrial fibrillation (AF). Compared with paroxysmal AF, the incidence of non-PV foci is higher in patients with persistent AF. Ablation of non-PV triggers is also important for patients with persistent AF and for those patients who undergo repeat ablation procedures in whom all PVs are found to be isolated. Accurate mapping/localization of non-PV triggers is a prime step and can be achieved with a systematic approach based on the analysis of the P wave morphology, intraatrial activation patterns at multipolar catheters in the standardized position of both atria, and the earliest activation site with direct recording. Ablation should be targeted at a specific site of origin or isolation of certain non-PV structures including superior vena cava, coronary sinus, posterior wall of the left atrium, and left atrial appendage.