A Case of Paroxysmal Atrial Fibrillation Triggered by Reentrant Pulmonary Vein Bigeminy

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A 42-year-old man was referred for catheter ablation of symptomatic paroxysmal atrial fibrillation (PAF). At baseline, there were frequent atrial premature contractions (APCs). The circular pulmonary vein (PV) mapping catheter in the right inferior PV (RIPV) exhibited PV bigeminy with or without conduction to the atria. The concealed premature PV potentials were conducted to the atria if the coupling interval of PV bigeminy was prolonged to 170 ms or more during coronary sinus (CS) pacing at a cycle length of 460 ms. Frequent APCs were associated with conducted PV bigeminy originating from the RIPV. As the cycle length of CS rapid pacing was shortened, the coupling interval of PV bigeminy was prolonged. Then, the PV bigeminy was suppressed by overdrive pacing at a cycle length of less than 430 ms. The S1–S2 coupling interval of CS extrastimulus pacing was inversely correlated with the coupling interval of PV bigeminy. And, PAF was triggered by conducted PV bigeminy originating from the RIPV after the coupling interval of PV bigeminy was prolonged. Circumferential PV isolation was performed. The PV bigeminy disappeared simultaneously with the achievement of RIPV isolation. These electrophysiological responses of the PV bigeminy to rapid or extrastimulus pacing suggested a reentrant mechanism.