Pulmonary vein isolation in cases of difficult catheter placement: A new pacing maneuver to demonstrate complete isolation of the veins

BackgroundPulmonary vein electrical isolation is the main goal of atrial fibrillation ablation. To ensure electrical isolation of the pulmonary veins, entrance and exit block should be demonstrated. However, this is sometimes challenging due to the complex anatomy of the pulmonary vein area and the anatomical variations that may preclude the correct position of the commonly used circular multielectrode catheter inside the veins.ObjectiveTo describe a new pacing maneuver useful to demonstrate complete isolation of ipsilateral veins in cases of difficult catheter placement.MethodsThree representative cases illustrate the usefulness of the maneuver either at the right or left pulmonary veins.ResultsAfter the circumferential ablation of ipsilateral veins, the circular catheter is positioned in one vein and the ablation catheter in the other ipsilateral vein. When local capture in one vein can be demonstrated while pacing from the other vein and no conduction to the atria is observed, isolation of both veins can be assured.ConclusionThis novel maneuver might be of help in assessing complete isolation of the pulmonary veins in cases of difficult circular catheter placement.