Revisiting non-pulmonary vein triggers

Non-pulmonary Vein (PV) triggers are usually found in other thoracic veins, i.e., superior vena cava, coronary sinus and vein of Marshall, and locations such as left atrial posterior wall (PW), crista terminalis, interatrial septum, and left atrial appendage. This chapter summarizes our approach for mapping and ablation of non-PV triggers, considering that PW isolation is performed empirically in all patients. When targeting non-PV triggers, atrial fibrillation (AF) ablation should be performed after an adequate washout of antiarrhythmic drugs (at least five half-lives) to minimize the chance of non-inducibility. Following pulmonary vein antral isolation and PW isolation, all patients are systematically challenged with isoproterenol 20-30µg/min for 10-15µmin to reveal reconnection of the PV and, most importantly, induce latent non-PV triggers. From an embryological, anatomical, and electrophysiological standpoint, it should be considered an extension of the PVs and its isolation has been proven to improve outcomes in paroxysmal and non-paroxysmal AF patients.