Novel atrial fibrillation (AF) ablation tools have been designed to facilitate “single-shot” pulmonary vein (PV) isolation using multi-electrode or balloon-based catheters. However, in contrast to point-by-point radiofrequency ablation, these tools may be more dependent on suitable PV anatomy to achieve circumferential PV isolation.

Three hundred and twenty-two patients underwent gadolinium-enhanced cardiac magnetic resonance angiography to delineate PV anatomy prior to initial AF ablation. Long (a) and short (b) axis measurements of the PV orifice were used to calculate the eccentricity index of the PV ostium.

Long axis dimensions of the left superior PV were 18.2 ± 3.3 mm, left inferior PV 17.7 ± 3.9 mm, right superior PV (RSPV) 20.4 ± 4.3, and right inferior PV 18.7 ± 4.7 mm. The long axis dimension of the RSPV was significantly larger than other PVs (p < 0.001). Forty-two patients (13 %) had at least one PV with a long axis dimension >25 mm and 16 patients (5 %) had at least one PV with a long axis dimension >28 mm. Left-sided PV ostia were significantly more ellipse-shaped than the right-sided PVs, which tended to be more spherical. A significant positive correlation was noted between increasing PV size and increased orifice eccentricity.

In this large cohort undergoing initial AF ablation, over 10 % of patients had at least one standard PV with a dimension >25 mm. Additionally, significant differences were noted between left- and right-sided veins with regard to orifice eccentricity. These findings have implications for the design of AF ablation tools and may account for differential isolation rates between PVs noted in some recent studies of novel ablation technologies.