© 2004 by European Society of Cardiology
CASE REPORT
Spontaneous and induced pulmonary vein tachycardia after pulmonary vein isolation
Catharina Hospital Eindhoven, The Netherlands
Manuscript submitted 20 January 2004. Accepted after revision 1 August 2004.
*Corresponding author. Department of Cardiology, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, The Netherlands. Tel.: +31 40 2397004; fax: +31 40 2447885. E-mail address: pepijn.vd.voort{at}cze.nl (P.H. van der Voort).
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A case is reported of recurrence of paroxysmal atrial fibrillation after pulmonary vein ablation. A second procedure achieved isolation of three pulmonary veins and showed persistence of pulmonary vein tachycardia in one with implications concerning the electrophysiology of atrial fibrillation.
Key Words: pulmonary vein tachycardia, pulmonary vein isolation, paroxysmal atrial fibrillation, radiofrequency ablation
A pulmonary vein (PV) ablation was performed in a 59-year-old man who had a recurrence of paroxysmal atrial fibrillation after an initial successful PV ablation procedure. During the first procedure, 7 months before, the right superior (RS) and left inferior (LI) PVs were isolated successfully. Isolation of the left superior (LS) and right inferior PV was not attempted because of their small diameter. During the second ablation procedure at both previously isolated PV ostia, the conduction had recovered. Initially, the LIPV was isolated successfully and also the LSPV was isolated this time. After placement of a Lasso catheter at the ostium of the RSPV short runs of irregular PV tachycardia were observed. A longer episode of PV tachycardia resulted in transient fibrillation of the atria. After disconnection of this RSPV, PV tachycardias were still present, but the atria were in sinus rhythm (Fig. 1). The PV tachycardia persisted for two more minutes after disconnection and, then, terminated spontaneously. After a short period of electrical silence in the PV, PV tachycardia recurred, lasting for another 3 min. Following this episode, no spontaneous electrical activity was observed in the PV for 15 min.
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After this period of electrical silence, we attempted to reinduce the PV tachycardia by programmed stimulation inside the PV, by stimulation at one electrode pair of the Lasso catheter, at basic cycle length (CL) 400 ms followed by one single extrastimulus; during pacing inside the PV, the atria were not captured and remained in sinus rhythm. Initially, no PV tachycardia could be induced, although the PV could be captured at very short coupling intervals of 80 ms (Fig. 2). To mimic the effects of atrial fibrillation in the PV, burst pacing was performed inside the PV at CL 100 ms, for 3 min. After this episode of burst pacing, sustained PV tachycardia could be induced very easily, even by one or two stimuli of the basic train at 400 ms (Fig. 3).
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After its initial description in 1997 [1]
, catheter ablation in and around the PVs has become a promising technique for treatment of atrial fibrillation. Complete electrical isolation of the arrhythmic pulmonary veins has proven to be successful.[2] Recently, Oral et al. described the occurrence of rapid PV tachycardias during atrial fibrillation [3]. They showed that the occurrence of these PV tachycardias was related to input of impulses from the left atrium. During atrial fibrillation, there might be interaction between the posterior wall of the left atrium and the PVs, with PV tachycardias maintaining fibrillation in the atrium and input from the left atrium reinducing PV tachycardia. In dogs, both microreentry [4] and triggered activity [5] have been observed as possible mechanisms for tachycardias inside the pulmonary veins. Rapid activity from the atria may facilitate both triggered activity and reentry. Electrophysiological properties of human pulmonary veins, including very short refractory periods and slow conduction, may create a substrate for local reentry [6]. In our patient, spontaneous activity in the RSPV stopped shortly after its electrical isolation from the left atrium and initially no PV tachycardia could be induced by single extrastimuli. However, after a period of rapid burst pacing, mimicking an input from the left atrium during AF, PV tachycardia could easily be induced. We cannot exclude the possibility that scar formation after the initial ablation had created a substrate for PV reentry. Furthermore, the possible role of autonomic nervous system has not been explored. Our observations support the hypothesis of an interaction between the left atrium and PVs, contributing to perpetuation of AF.
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[1] Jaïs P, Haïssaguerre M, Shah D, et al. A focal source of atrial fibrillation treated by discrete radiofrequency ablation. Circulation 1997; 95: 572–576.
[2] Haïssaguerre M, Jaïs P, Shah D, et al. Electrophysiological end point for catheter ablation of atrial fibrillation initiated from multiple pulmonary venous foci. Circulation 2000; 101: 1409–1417.
[3] Oral H, Knight BP, Tada H, et al. Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation 2002; 105: 1077–1081.
[4] Hocini M, Ho SY, Kawara T, et al. Electrical conduction in canine pulmonary veins. Electrical and anatomic correlation. Circulation 2002; 105: 2442–2448.
[5] Chen YJ, Chen SA, Yeh HI, et al. Effects of rapid atrial pacing on the arrhythmogenic activity of single cardiomyocytes from pulmonary veins. Implication in initiation of atrial fibrillation. Circulation 2001; 104: 2849–2854.
[6] Jaïs P, Hocini M, Macle L, et al. Distinctive electrophysiological properties of pulmonary veins in patients with atrial fibrillation. Circulation 2002; 106: 2479–2485.
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