Figure legend
Figure 1 Illustration of AEPVR and Endocardial Conduction Gap. A: A patient showing AEPVR 35 minutes after first-pass isolation. The earliest distal activation site was located at posterior PV antrum, 18.6mm distant from the prior ablation line without near-field electrograms along the lesion. A centrifugal activation pattern within the circle was demonstrated. B: A patient showing PVR due to endocardial gap at the roof of LPV present 22 minutes after first-pass isolation. Electrograms at the breakthrough site (cyan dot) demonstrated near-field fractionated potentials preceding PV potentials. AEPVR=acute epicardial pulmonary vein reconnection; LAPW=left atrial posterior wall; LPV=left pulmonary vein; RPV=right pulmonary vein.
Figure 2 Observation Time before PVR in the Groups of AEPVR and Gap. Scatter plot showed that AEPVR required longer waiting period (40.3±11.9 vs. 29.3±9.4 minutes, P <0.001) than endocardial gap, counted from the time of PV isolation to the identification of PVR. AEPVR=acute epicardial pulmonary vein reconnection.
Figure 3 Distribution of AEPVR, Endocardial Gap and Delayed Epicardial PVR. Most AEPVR and late epicardial PVR found in repeat procedures were located at interpulmonary isthmus of PVs, while endocardial gaps were widely distributed around the circle. AEPVR=acute epicardial pulmonary vein reconnection; LIPV=left inferior pulmonary vein; LSPV=left superior pulmonary vein; RIPV=right inferior pulmonary vein; RSPV=right superior pulmonary vein.
Figure 4 Localization of Proximal Insertion Sites of AEPVR with PV Pacing. A: During PV pacing in a patient showing AEPVR at left posterior PV antrum, the proximal insertion site were mapped and located at inferior posterior wall with a diffuse activation pattern based on the nearly identical timing in a small area (yellow dotted line). Also note the intracardiac echocardiographic contour of esophagus was in close proximity to the left PV antrum. B: AEPVR at right posterior PV antrum was connected to the posterior wall in a slightly oblique direction with localized activation pattern at the proximal end; C: Pacing at the right anterior carina with low output demonstrated earliest activation on the posterior wall of the right atrium where double potentials were shown. The near-field right atrial potentials (white dotted line) were preceded by the far-field PV potentials (yellow dotted line). The asterisks showed the earliest distal insertion mapped within PVs during sinus rhythm. AEPVR=acute epicardial pulmonary vein reconnection; ESO=esophagus; LAPW=left atrial posterior wall; LPV=left pulmonary vein; RAPW=right atrial posterior wall; RPV=right pulmonary vein; SVC=superior vena cava.
Figure 5 ROC Analysis of Different Prediction Indexes to Predict AEPVR. The integrated model containing multiple lesion set parameters had the largest AUC for predicting the presence of AEPVR both in the whole cohort (A) and in patients with acute PVR (B). AEPVR=acute epicardial pulmonary vein reconnection; AI=ablation index; CF=contact force; ID=impedance drop; ROC= receiver operating characteristic.