Recurrent persistent atrial fibrillation after effective pulmonary vein isolation: What else?

Pulmonary vein isolation (PVI) is the mainstay of every atrial fibrillation (AF) ablation procedure. However, it is still debated in the literature whether PVI alone is sufficient to achieve long-term freedom from atrial tachyarrhythmias in patients with non-paroxysmal AF. Hereby, we discuss the hypothetical clinical scenario of a patient with AF relapse 6 months after PVI in whom all pulmonary veins are electrically silent at the time of repeat ablation.