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Electrical Connections Between Pulmonary Veins in Humans

2001; Lippincott Williams & Wilkins; Volume: 104; Issue: 7 Linguagem: Inglês

10.1161/hc3201.094105

1524-4539

Massimo Tritto, Roberto De Ponti, Marco Zardini, Giammario Spadacini, Mario Oliveira, Jorge A. Salerno‐Uriarte,

Cardiac pacing and defibrillation studies

HomeCirculationVol. 104, No. 7Electrical Connections Between Pulmonary Veins in Humans Free AccessOtherPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherPDF/EPUBElectrical Connections Between Pulmonary Veins in HumansEvidence After Radiofrequency Ablation of the Venoatrial Junction Massimo Tritto, Roberto De Ponti, Marco Zardini, Giammario Spadacini, Mario Oliveira and Jorge A. Salerno-Uriarte Massimo TrittoMassimo Tritto From the Cardiology Department "Mater Domini," University of Insubria, Varese, Italy. , Roberto De PontiRoberto De Ponti From the Cardiology Department "Mater Domini," University of Insubria, Varese, Italy. , Marco ZardiniMarco Zardini From the Cardiology Department "Mater Domini," University of Insubria, Varese, Italy. , Giammario SpadaciniGiammario Spadacini From the Cardiology Department "Mater Domini," University of Insubria, Varese, Italy. , Mario OliveiraMario Oliveira From the Cardiology Department "Mater Domini," University of Insubria, Varese, Italy. and Jorge A. Salerno-UriarteJorge A. Salerno-Uriarte From the Cardiology Department "Mater Domini," University of Insubria, Varese, Italy. Originally published14 Aug 2001https://doi.org/10.1161/hc3201.094105Circulation. 2001;104:e30–e31A 47-year-old man with an uncorrected ostium primum atrial septal defect complained of frequent episodes of paroxysmal atrial fibrillation since 1990. Class IC and III antiarrhythmic drugs failed to control the recurrences, and the patient was referred to our institution for electrophysiological evaluation. During the procedure, the focal origin of the atrial fibrillation episodes from the right superior and left pulmonary veins (PVs) was demonstrated by means of multielectrode mapping. For this reason, after selective PV angiography, PV electrical disconnection attempts were performed by delivering low-energy radiofrequency pulses close to the corresponding venoatrial junctions. To facilitate the recognition of electrical PV disconnection, a double-catheter technique was used with a reference quadripolar catheter placed distally in the mapped PV and a quadripolar, 4-mm tip, steerable catheter positioned immediately within the ostium of the same vein for mapping and ablation. Target areas were considered those exhibiting the shortest venoatrial conduction time (in sinus rhythm or distal coronary sinus atrial pacing during right or left PV mapping), as measured from the distal couple of electrodes of the mapping catheter. If changes in the activation breakthrough occurred after radiofrequency applications, the mapping catheter was moved to another segment of the PV perimeter showing the shortest venoatrial conduction time. Electrical disconnection occurred when the PV potentials abruptly disappeared or were dissociated from the atrial potentials during radiofrequency delivery.Because the right superior PV focus was the most active in triggering atrial fibrillation episodes, it was the first targeted by radiofrequency applications. Thereafter, the left inferior PV was approached, but only a decrease of the PV potential amplitude and a delay in the venoatrial conduction was obtained. Finally, the left superior PV was disconnected with the last radiofrequency pulse delivered at the floor of the venoatrial junction (Figure 1). To complete the procedure, the reference catheter was then reinserted in the left inferior PV for further mapping, while the mapping catheter was kept in the superior branch at the ablation site. Surprisingly, dissociated PV potentials were also recorded in the inferior vein, resulting from a vein-to-vein transmission of the spontaneous left superior PV automatic discharges (Figure 2). This finding unequivocally demonstrates, for the first time in humans, the presence of electrical conduction between PVs and may imply that treatment of contiguous vessels might be required when PV electrical disconnection procedures are attempted. Download figureDownload PowerPointFigure 1. Left superior PV (LSPV) electrical disconnection. From top to bottom, surface ECG lead V1 is displayed together with bipolar intracardiac recordings obtained from the distal (d) and proximal (p) poles of the coronary sinus (CS) and the left superior PV reference (REF) and ablation (ABL) catheters. A, During distal coronary sinus atrial pacing, the left superior PV reference catheter recorded 2 separate, sharp electrograms reflecting the left atrial and PV (*) activations. A single, multicomponent electrogram timed between the atrial and PV activations is recorded by the distal electrodes of the left superior PV ablation catheter placed at the venoatrial conduction breakthrough. B, Radiofrequency (RF) current delivery at this site produces PV electrogram disappearance (arrow) preceded by an increase in the left atrial–PV conduction time. The dissociated PV activity reappears in the right part of the panel.Download figureDownload PowerPointFigure 2. Electrical conduction between the left PVs. A and B, Left superior (LS) and inferior (LI) PV–selective angiograms in the anteroposterior view. RSPV indicates right superior pulmonary vein catheter; CS, coronary sinus catheter. C, Fluoroscopic position of the left superior and inferior PV catheters after left superior PV electrical disconnection. D, Spontaneous left superior PV discharges (sharp electrograms indicated by arrowheads in the LSPVd recordings), dissociated from the left atrial activation, are directly transmitted (ie, without an interposed left atrial activation) to the left inferior PV (sharp electrograms indicated by *), demonstrating a vein-to-vein electrical conduction. Because the left superior PV catheter crosses the line of conduction block, no PV potentials are recorded from the proximal pair of electrodes. Abbreviations as in Figure 1.The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke's Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.FootnotesCorrespondence to Massimo Tritto, MD, Cardiology Department "Mater Domini," University of Insubria—Varese, v Gerenzano 2, 21053 Castellanza (VA), Italy. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetailsCited By Miyazaki S, Hasegawa K, Nodera M, Mukai M, Aoyama D, Sekihara T, Eguchi T and Tada H (2021) The impact of electrical connections between left ipsilateral pulmonary veins on the time-to-isolation values in cryoballoon ablation, Journal of Interventional Cardiac Electrophysiology, 10.1007/s10840-021-01034-7, 64:3, (581-586), Online publication date: 1-Sep-2022. Hirao T, Yamauchi Y, Nakamura R, Shigeta T, Yoshida H, Tachibana S, Oda A, Ito A, Asano M, Suzuki H, Shimura T, Kurabayashi M, Goya M, Okishige K and Sasano T (2021) Predictors of the "Crosstalk" Phenomenon During Cryoballoon Ablation in Patients with Atrial Fibrillation, International Heart Journal, 10.1536/ihj.20-690, 62:2, (320-328), Online publication date: 30-Mar-2021. Miyazaki S, Kajiyama T, Watanabe T, Hada M, Nakamura H, Hachiya H, Tada H, Hirao K and Iesaka Y (2018) Impact of electrical connections between ipsilateral pulmonary veins on the second-generation cryoballoon ablation procedure, Journal of Cardiovascular Electrophysiology, 10.1111/jce.13731, 30:1, (27-31), Online publication date: 1-Jan-2019. Squara F, Liuba I, Chik W, Santangeli P, Maeda S, S. Zado E, Callans D and Marchlinski F (2015) Electrical connection between ipsilateral pulmonary veins: Prevalence and implications for ablation and adenosine testing, Heart Rhythm, 10.1016/j.hrthm.2014.11.003, 12:2, (275-282), Online publication date: 1-Feb-2015. PÉREZ-CASTELLANO N, VILLACASTÍN J, SALINAS J, VEGA M, MORENO J, DOBLADO M, RUIZ E and MACAYA C (2010) Epicardial Connections Between the Pulmonary Veins and Left Atrium: Relevance for Atrial Fibrillation Ablation, Journal of Cardiovascular Electrophysiology, 10.1111/j.1540-8167.2010.01873.x, (no-no) Cabrera J, Ho S, Climent V, Fuertes B, Murillo M and Sánchez-Quintana D (2009) Morphological evidence of muscular connections between contiguous pulmonary venous orifices: Relevance of the interpulmonary isthmus for catheter ablation in atrial fibrillation, Heart Rhythm, 10.1016/j.hrthm.2009.04.016, 6:8, (1192-1198), Online publication date: 1-Aug-2009. 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SCHWARTZMAN D, BAZAZ R and NOSBISCH J (2004) Common Left Pulmonary Vein:, Journal of Cardiovascular Electrophysiology, 10.1046/j.1540-8167.2004.03351.x, 15:5, (560-566) MANSOUR M, HOLMVANG G, SOSNOVIK D, MIGRINO R, ABBARA S, RUSKIN J and KEANE D (2004) Assessment of Pulmonary Vein Anatomic Variability by Magnetic Resonance Imaging:. Implications for Catheter Ablation Techniques for Atrial Fibrillation, Journal of Cardiovascular Electrophysiology, 10.1046/j.1540-8167.2004.03515.x, 15:4, (387-393), Online publication date: 1-Apr-2004. RAJAWAT Y, GERSTENFELD E, PATEL V, DIXIT S, CALLANS D and MARCHLINSKI F (2004) ECG Criteria for Localizing the Pulmonary Vein Origin of Spontaneous Atrial Premature Complexes:. Validation Using Intracardiac Recordings, Pacing and Clinical Electrophysiology, 10.1111/j.1540-8159.2004.00408.x, 27:2, (182-188), Online publication date: 1-Feb-2004. YEN HO S (2003) Pulmonary Vein Ablation in Atrial Fibrillation:, Journal of Cardiovascular Electrophysiology, 10.1046/j.1540-8167.2003.02551.x, 14:2, (156-157) Zobel C, Kassiri Z, Nguyen T, Meng Y and Backx P (2002) Prevention of Hypertrophy by Overexpression of Kv4.2 in Cultured Neonatal Cardiomyocytes, Circulation, 106:18, (2385-2391), Online publication date: 29-Oct-2002. August 14, 2001Vol 104, Issue 7 Advertisement Article InformationMetrics https://doi.org/10.1161/hc3201.094105 Originally publishedAugust 14, 2001 PDF download Advertisement