Europace Advance Access originally published online on August 29, 2008
Europace 2008 10(11):1349-1350; doi:10.1093/europace/eun242
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
CASE REPORTS
A common inferior pulmonary trunk detected by computed tomography affects atrial fibrillation ablation strategy
Stefan Pfaffenberger*,
Marianne Gwechenberger,
Bernhard Richter and
Heinz D. Goessinger
Department of Cardiology, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
* Corresponding author. Tel: +431404004614; fax: +431404004216. E-mail address: stefan.pfaffenberger{at}meduniwien.ac.at
 |
Abstract
|
|---|
Pulmonary veins (PV) display a variety of anomalies with a common
trunk of the inferior pulmonary veins being the most infrequent.
We report on a 65-year-old man who underwent an ablation procedure
for atrial fibrillation (AF) exclusively based on electro-anatomical
mapping. After recurrence of AF, a common trunk of the inferior
PV was detected by computed tomography imaging resulting in
a modified ablation approach. Due to a possible role of the
common inferior trunk for the initiation of AF, a repeat procedure
was performed by en bloc isolation of the common inferior trunk
with the left superior PV. The right superior PV was ablated
separately. Off antiarrhythmic medication, the patient has remained
free of any arrhythmia during a 14 month follow-up.
|
Introduction
|
|---|
Pulmonary veins (PVs) display a variety of anomalies with a
common trunk of the inferior PVs being the most infrequent.
In larger series, the incidence of the common inferior trunk
ranges from 0 to 0.9% in patients with atrial fibrillation (AF).
1
We report on a patient with failed ablation of AF exclusively
based on electro-anatomical mapping. A successful repeat procedure
was performed after the detection of a common trunk of the inferior
PVs by computed tomography (CT) imaging resulting in a modified
ablation approach.
|
Case report
|
|---|
A 65-year-old man with a history of hypertension and drug refractory
paroxysmal AF underwent catheter ablation. Based on CARTO-mapping
circumferential ablation of the PVs with a common posterior
line was carried out (
Figure 1A). In addition, a touch-up
Lasso-catheter (Biosense Webster, Inc., Diamond Bar, CA, USA)
guided isolation at the venoatrial junction was performed for
all PVs except for the left inferior PV, which could not be
probed. Because of recurrent episodes of AF, a repeat procedure
was undertaken 8 months later. A multi-slice CT scan revealed
a slightly enlarged left atrium with normally positioned left
and right superior PVs and a common trunk of the inferior PVs.
During the electrophysiological study, the CT image was integrated
into the CARTO-map. All PVs showed reconnection to the atrium.
Owing to a possible role of the common inferior trunk for the
initiation of AF, the common inferior trunk was isolated en
bloc with the left superior PV. The right superior PV was ablated
separately (
Figure 1B). Off antiarrhythmic medication,
the patient has remained free of any arrhythmia during a 14
months follow-up, also supported by the results of a 6-day-Holter-monitoring.
Anticoagulation was ceased 3 months after ablation.
View larger version (67K):
[in this window]
[in a new window]
[Download PowerPoint slide]
|
Figure 1 (A) Posterior view of the left atrial CARTO-map with circumferential PV isolation and a common posterior ablation line in a patient with an undetected common trunk of the inferior PVs. (B) Multi-slice CT imaging (posterior view) of the left atrium displaying a common inferior pulmonary trunk with a 90° perpendicular take-off of the left inferior PV and a right inferior PV continuing the direction of the common trunk. Ablation sites comprise en bloc isolation of the inferior pulmonary trunk and the left superior PV and isolation of the right superior PV, separately. Abbreviations: LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein.
|
|
|
Discussion
|
|---|
The presence of a common inferior trunk poses a problem for
an ablation procedure of AF. As shown by the present case, this
anomaly easily goes undetected by the use of electro-anatomical
mapping alone. This may also be supported by the fact that all
the reported cases in literature rely on either CT scan or MR
imaging.
1–3 It is possible that the catheter induced pressure
exerted to the left atrial wall distorts the atrial shape thus
preventing the delineation of this anomaly. However, there may
be clues towards the presence of a common inferior trunk, namely
the inability either to avoid a common posterior line during
circumferential PV isolation or to probe the left inferior PV
with a Lasso catheter because of a 90° rectangular take-off
of this vein. However, it is possible that the repeat successful
ablation is mainly due to the complete isolation of the superior
PVs, especially the left superior PV, a common site for AF focal
triggers. Nevertheless, the presence of a common inferior trunk
suggests the need for its isolation either individually or combined
with the left superior PV as shown in the present case.
2,3
Conflict of interest: none declared.
|
References
|
|---|
[1] Yu R, Dong J, Zhang Z, Liu X, Kang J, Long D, et al. Characteristics in image integration system guiding catheter ablation of atrial fibrillation with a common ostium of inferior pulmonary veins. Pacing Clin Electrophysiol (2008) 31:93–8.
[Medline][2] Marazzi R, De Ponti R, Lumia D, Fugazzola C, Salerno-Uriarte JA. Common trunk of the inferior pulmonary veins: an unexpected anatomical variant detected before ablation by multi-slice computed tomography. Europace (2007) 9:121.[Free Full Text]
[3] Lickfett L, Lewalter T, Nickenig G, Naehle P. Common trunk of the right and left inferior pulmonary veins: previously unreported anatomic variant with implications for catheter ablation. Heart Rhythm (2007) 4:1244–5.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
Top
Abstract
Introduction