The egg or the chicken?

In this issue of the Journal of Geriatric Cardiology, Gao et al.,1 in a report of increased ostial pulmonary vein diameter by multislice CT angiography reported a statistically signifi-cant enlargement of the pulmonary veins in patients with con-gestive heart failure (CHF). This finding alone should not be of any surprise as anatomic remodeling and general dilation of the cardiac chambers are well described in patients with CHF. What is thought provoking is the conjecture that pulmonary vein ostial dilation may play a role in the genesis and mainte-nance of atrial fibrillation. Multiple theories of the mechanism of atrial fibrillation exist, but it is safe to assume that disper-sion of refractoriness in the left atrium is a necessary condi-tion to maintain atrial fibrillation. Whether the mere anatomi-cal change of the pulmonary vein ostia in CHF is sufficient to create this dispersion of refractoriness is a matter of hot debate. This report by Gao et al. however, is important in the implica-tion of the use of this novel imaging technique for the purpose of identifying and visualizing the pulmonary vein ostia for atrial fibrillation ablation.