wave front propagation, especially in low voltage zones. By performing HDM mapping inside the PVAI lines after conventional encirclement lesions, we hoped to identify any RPs associated with ECs inside our PVAI lines. Thus, the purpose of this study was to determine the prevalence and number of ECs inside the PVAI lines after a conventional PVAI, and the effect of an EC ablation on the outcomes in patients with non-valvular paroxysmal (pAF), persistent (persAF), and long-lasting AF (LLAF). Methods Baseline Clinical Characteristics of the Patient GroupsThe present study was approved by the institutional review committee and ethics review board of our hospital, the Ethical Review Board of Steel Memorial Yawata Hospital. The procedures were followed in accordance with the Declaration of Helsinki and the ethical standards of the responsible committee on human experimentation. Moreover, we enrolled this study in an international registry of P ulmonary vein (PV) antrum isolation (PVAI) with radiofrequency catheter ablation (RFCA) has proven to be a useful strategy for atrial fibrillation patients (AF) worldwide. 1 To prevent initiating and maintaining AF, a complete PVAI should be a target of the AF treatment. 1 However, in spite of establishing complete PVAI lines, we rarely experience and encounter remaining potentials (RPs) inside our PVAI lines detected by high-density mapping (HDM). Then, when we perform pacing from the ablation catheter on the RPs inside our PVAI lines, we confirm that the pacing can capture RPs and conduct to the atrium. This finding indicates the existence of epicardial connection(s) (ECs) from inside the PVAI lines to the atrium after establishing complete conventional PVAI lines. The recent Intellamap Orion 2 (Boston Scientific Corporation, Marlborough, MA, USA) and Advisor TM HD Grid 3 (Abbott, Plymouth, MN, USA) advanced catheter technologies, which are directional HDM catheters, can not only identify low voltages and small local electrical signals, but also more importantly can capture the direction of the

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Background Recent reports have demonstrated that approximately 10% of patients with atrial fibrillation (AF) have epicardial connections (ECs) inside the pulmonary vein (PV) antrum isolation (AI) (PVAI) lines, which could be a possible mechanism of failure to achieve a complete PVAI, thus contributing to AF recurrence. Case summary We present an 80-year-old female case with consistently continuing AF associated with ECs. ECs involving the PVs were detected in the left and right superior PVs after the completion of the PVAI. The AF steadily terminated after the ablation of those ECs. She has remained well without any AF or symptoms for 2-years post-ablation. Discussion Those ECs might have played a possible important role in initiating and maintaining the AF. The mechanism(s) of the ECs may be a cornerstone of the failure to achieve a complete PVAI contributing to AF recurrence. Ablation of the EC(s) in addition to the PVAI may be better able to achieve the completion of the PVAI. Thus, physicians should be aware of the possibility of the presence of EC(s) when performing ablation of AF, even though complete PVAI lines have been achieved.

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