Europace Advance Access published online on April 9, 2008
Europace, doi:10.1093/europace/eun074
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CASE REPORT
Verification of electrical isolation of pulmonary veins following left atrial circumferential ablation may require sinus rhythm
Department of Cardiology, Queen Elizabeth Medical Centre, University Hospitals NHS Trust, Edgbaston, Birmingham B15 2TH, UK
Manuscript submitted 21 December 2007. Accepted after revision 5 March 2008.
* Corresponding author. Tel: +44 121 472 1311; fax: +44 121 627 2093. E-mail address: michael.griffith{at}uhb.nhs.uk
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Abstract |
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A 67-year-old female with symptomatic paroxysmal atrial fibrillation (AF) underwent left atrial circumferential ablation, and during the procedure, she developed AF. Once the ablation was complete, the left upper pulmonary vein (LUPV) appeared to continue in a rapid disorganized rhythm, despite further attempts at isolating this vein. When the patient was electrically cardioverted to sinus rhythm to assist mapping, the LUPV remained in a disorganized rhythm, pulmonary vein (PV) fibrillation. This case illustrates a possible pitfall in confirming complete isolation of the PVs during AF.
Key Words: Catheter ablation, Atrial fibrillation, Pulmonary vein
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Introduction |
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Isolation of the pulmonary veins (PVs) is thought by many to be very important in the treatment of atrial fibrillation (AF).1
–3 It can be demonstrated easily in sinus rhythm or increasingly in AF. We report a case in which following a left atrial circumferential ablation (LACA), the patient remained in AF and complete isolation of the PVs could only be confirmed following electrical cardioversion of the atria to sinus rhythm. |
Case report |
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An active 67-year-old woman was referred to the outpatient department with a 5 year history of symptomatic documented paroxysmal AF. The symptoms were predominantly palpitations and breathlessness and occurred on average once per week. At the time of referral she had been taking warfarin and sotalol 40 mg twice per day. Her previous medication included flecainide, digoxin, and bisoprolol, all of which had not provided any symptomatic improvement. She was a non-smoker and consumed occasional alcohol. An echocardiogram revealed mild mitral regurgitation with no chamber dilatation. She elected to have radiofrequency LACA performed to cure her symptoms.
A 3-D electroanatomical mapping technique was employed (CARTO XP Navigation System, Biosense Webster, Diamond Bar, CA, USA). A 6-Fr quadripolar catheter was introduced from the left subclavian vein and placed in the coronary sinus (Biosense Webster, Diamond Bar, CA, USA). A 6-Fr lasso variable circular catheter (Biosense Webster, Diamond Bar, CA, USA) and an irrigated tip mapping/ablation catheter (Thermocool Irrigated Tip Catheter, Biosense Webster Diamond Bar, CA, USA) were introduced into the left atrium following a trans-septal puncture via the right femoral vein. During the initial part of the procedure, the patient spontaneously went into AF. Left atrial circumferential ablation was performed guided by the 3-D mapping and fluoroscopic imaging. Initially, the left veins were isolated using radiofrequency lesions were placed circumferentially in the antral areas of the PVs. The procedure was repeated on the right side. As per our usual protocol, each PV was then mapped using the lasso catheter and additional lesions were placed adjacent to the ostium to ensure vein isolation. Following this procedure, all veins appeared isolated apart from the left upper pulmonary vein (LUPV) which despite further lesions being placed near the ostium continued to have a chaotic electrogram pattern, suggesting that it was still connected. Atrial fibrillation persisted at this point. Direct Current (DC) cardioversion was undertaken to facilitate mapping and further ablation in sinus rhythm. The patient's atria were successfully cardioverted to sinus rhythm, following a single synchronized DC shock of 150 J. The LUPV persisted with a chaotic rhythm while the remainder of the heart was in sinus rhythm (Figure 1), suggesting successful isolation of the LUPV. This rhythm spontaneously terminated 10 min later and pacing in the vein could not re-induce the rhythm (Figure 2).
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Discussion |
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We used a combined technique of circumferential ablation and then mapping of each PV using a lasso catheter with further ablation to achieve complete isolation of each PV. This combined technique is reported to have cure rates of 90%,4
,5 but relies on the strong endpoint of complete PV isolation. Other authors have described isolation of the vein cardioverting the atria to sinus rhythm, with continuing PV tachycardia in the vein, or an organized rhythm in the vein with continued AF in the atria.6,7 In both these scenarios, vein isolation is clearly evident. This case describes a chaotic rhythm in the isolated vein, whose isolation was only possible to prove when the atrium was electrically cardioverted. The mechanism of this PV rhythm is not clear, but Huang et al.8 in which one case where the PV tachycardia required DC cardioversion. |
Conclusion |
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If effective antral ablation fails to organize the electrograms in the PV, then cardioversion may reveal isolation.
Conflict of interest: none declared.
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References |
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[1] Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med (1998) 339:659–66.
[2] Pappone C, Oreto G, Rosanio S, Vicedomini G, Tocchi M, Gugliotta F, et al. Atrial electroanatomic remodeling after circumferential radiofrequency pulmonary vein ablation: efficacy of an anatomic approach in a large cohort of patients with atrial fibrillation. Circulation (2001) 104:2539–44.
[3] Pappone C, Rosanio S, Augello G, Gallus G, Vicedomini G, Mazzone P, et al. Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study. J Am Coll Cardiol (2003) 42:185–97.
[4] Ouyang F, Bansch D, Ernst S, Schaumann A, Hachiya H, Chen M, et al. Complete isolation of left atrium surrounding the pulmonary veins: new insights from the double-Lasso technique in paroxysmal atrial fibrillation. Circulation (2004) 110:2090–6.
[5] Verma A, Wazni OM, Marrouche NF, Martin DO, Kilicaslan F, Minor S, et al. Pre-existent left atrial scarring in patients undergoing pulmonary vein antrum isolation: an independent predictor of procedural failure. J Am Coll Cardiol (2005) 45:285–92.
[6] van der Voort PH, Meijer A. Spontaneous and induced pulmonary vein tachycardia after pulmonary vein isolation. Europace (2004) 6:613–6.
[7] Tada H, Naito S, Asakawa T, Taniguchi K. Persistent tachycardia with a 2:1 exit block within an isolated pulmonary vein. J Interv Card Electrophysiol (2004) 10:73–7.[CrossRef][Web of Science][Medline]
[8] Huang H, Wang X, Chun J, Ernst S, Satomi K, Ujeyl A, et al. A single pulmonary vein as electrophysiological substrate of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol (2006) 17:1193–201.[CrossRef][Web of Science][Medline]
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