Left Common Pulmonary Vein Research Articles

Left Atrial Anatomy in Patients Undergoing Ablation for Atrial Fibrillation.

Background: Left atrial anatomy is highly variable, asymmetric, irregular and three-dimensionally unique. This variability can affect the outcome of atrial ablation. A catalog of anatomic varieties may aid patient selection and ablation approach and provide better tools for left atrial ablation. Methods: We analyzed computed tomography scans from 514 patients undergoing left atrial ablation. Images were processed on Advantage Windows with CardEP™ software (GE Healthcare, Waukesha, WI). Measurements of pulmonary vein (PV) ostial size along the long and short axes were made using double oblique cuts, and area of the ostia was calculated. Results: Patients with 2 left (LPV) and 2 right PVs (RPV) (62.6%), 2 LPVs and 3 RPVs (17.3%) and 1 LPV and 2 RPVs (14.2%) made up the three most common variants. In the 2-LPV/2-RPV anatomy, the ostial size and area of the RPVs were larger than their corresponding LPVs (p<0.001), and the ostial size and area of the superior PVs were larger than their corresponding inferior PVs (p<0.001). In the 2-LPV/3-RPV anatomy, the total area of the RPVs was larger than the total area of the LPVs (p<0.001). In the 1-LPV/2-RPV anatomy, the ostial size of the left common PV was larger than either right PV (p<0.007). However, the total area of the RPVs was larger than the area of the left common PV (p<0.002). The left common PV was also larger than any of the left veins in any of the other anatomies. The total PV area between the three most common anatomies was not significantly different. Conclusions: More than 37% of patients have a left atrial anatomy other than 2 left and 2 right PVs. This data may help in designing approaches for left atrial ablation, tailoring the procedure to individual patients and improving ablation tools.

Assessment of exit block following pulmonary vein isolation: Far-field capture masquerading as entrance without exit block

Complete electrical isolation of pulmonary veins (PVs) remains the cornerstone of ablation therapy for atrial fibrillation. Entrance block without exit block has been reported to occur in 40% of the patients. Far-field capture (FFC) can occur during pacing from the superior PVs to assess exit block, and this may appear as persistent conduction from PV to left atrium (LA). To facilitate accurate assessment of exit block. Twenty consecutive patients with symptomatic atrial fibrillation referred for ablation were included in the study. Once PV isolation (entrance block) was confirmed, pacing from all the bipoles on the Lasso catheter was used to assess exit block by using a pacing stimulus of 10 mA at 2 ms. Evidence for PV capture without conduction to LA was necessary to prove exit block. If conduction to LA was noticed, pacing output was decreased until there was PV capture without conduction to LA or no PV capture was noted to assess for far-field capture in both the upper PVs. All 20 patients underwent successful isolation (entrance block) of all 76 (4 left common PV) veins: mean age 58 ± 9 years; paroxysmal atrial fibrillation 40%; hypertension 70%, diabetes mellitus 30%, coronary artery disease 15%; left ventricular ejection fraction 55% ± 10%; LA size 42 ± 11 mm. Despite entrance block, exit block was absent in only 16% of the PVs, suggesting persistent PV to LA conduction. FFC of LA appendage was noted in 38% of the left superior PVs. FFC of the superior vena cava was noted in 30% of the right superior PVs. The mean pacing threshold for FFC was 7 ± 4 mA. Decreasing pacing output until only PV capture (loss of FFC) is noted was essential to confirm true exit block. FFC of LA appendage or superior vena cava can masquerade as persistent PV to LA conduction. A careful assessment for PV capture at decreasing pacing output is essential to exclude FFC.

Comprehensive surgical approach to treat atrial fibrillation in patients with variant pulmonary venous anatomy

Catheter radiofrequency ablation procedures yield fairly successful results for the treatment of atrial fibrillation; however, patients with anatomic variant pulmonary veins (PV) are generally thought not to benefit from catheter ablation technique, with recurrence rates observed as high as 78%. We report a comprehensive surgical approach to treat this subset of patients with a modified full maze procedure. From January 2002 to December 2009, 72 patients undergoing cardiac surgery who had drug-refractory and/or recurrent AF after catheter ablation were identified. PV variance was observed on preoperative multislice chest computed tomography. All patients underwent multiple PV epicardial circumferential isolation and epicardial-endocardial longitudinal PV ablations along with standard maze as an adjunct to the cardiac surgical procedure. Patients were followed up at 6 months, 1 year, and 2 years postoperatively. Typical patterns of PV variation were observed in 72 patients. Left common PV trunk was found in 49 patients (68%), with a mean length of 21 ± 4.6 mm, diameter of 28.6 ± 4.9 mm, and wall thickness of 2.1 ± 1.7 mm. Right PV variants, including right middle and right top PVs, were found in 23 patients (32%), with a length of 20 ± 2.1 mm, diameter of 9.9 ± 3.4 mm, and wall thickness of 1.9 ± 1.7 mm. Overall restoration of sinus rhythm was confirmed in 64 patients (94%) at 1-year follow-up. Twelve patients were defibrillated into sinus rhythm within 90 days after the operation. A modified full maze procedure should be considered as a first choice treatment for atrial fibrillation with variant drainage of PVs because of the nature of PV size, wall thickness, and specific foci in the arrhythmogenic veins. Multiple PV isolation and epicardial-endocardial longitudinal PV ablations along with the standard maze are essential to success. Early referral for surgical ablation allows higher success rates.

Normal Pulmonary Veins Anatomy is Associated with Better AF‐Free Survival after Cryoablation as Compared to Atypical Anatomy with Common Left Pulmonary Vein

Pulmonary vein cryoablation (PVC) is a new approach in the treatment of recurrent atrial fibrillation (AF). Computed tomography (CT) can be used to evaluate the left atrium anatomy and PVs dimensions to facilitate the procedure. In radiofrequency procedures, some anatomic variants such as common left (CLPV) or right (CRPV) PV were reported as factors associated with technical procedure difficulties and potential long-term complications. We hypothesized that the absence of CLPV as determined by CT would predict better AF-free survival after PVC. We included 118 consecutive patients (mean age 56 ± 10 years; 77% males) with drug refractory paroxysmal (72%)/persistent (28%) AF, with more than 6 months follow-up, who underwent PVC. On CT scanning images performed within 1 month prior to ablation, we evaluated PV anatomic patterns: presence of CLPV or CRPV. Each patient was evaluated by 24-hour Holter monitoring within 1 and 3 months and all patients were periodically evaluated at 1, 3, and 6 months, and every 6 months thereafter. Patients were asked to record their 12-lead electrocardiogram whenever they experienced symptoms suggestive of AF. Recurrence was defined as AF that lasted at least 30 seconds. CLPV was present in 30 (25%) patients and no patients with CRPV were identified. At the end of the 13 months follow-up, patients with normal PVs had significantly better AF-free survival compared to patients with CLPV (67% vs 50%, P = 0.02). The difference was present in patients with paroxysmal AF (P = 0.008) but not in patients with persistent AF (P = 0.92). In patients undergoing cryoballoon PV isolation for AF, the presence of normal PVs pattern is associated with better AF-free survival as compared to atypical PV anatomy with CLPV, particularly in patients with paroxysmal AF.

A New Method of a Pulmonary Vein Map to Identify a Conduction Gap on the Pulmonary Vein Antrum Ablation Line

Electrical isolation of the pulmonary veins (PV) is crucial for atrial fibrillation (AF) ablation. Conduction gaps on the circumferential PV antrum ablation (CPVA) line sometimes remain, which are sometimes difficult to identify. CPVA of the ipsilateral superior and inferior PVs was performed during sinus rhythm or coronary sinus pacing using the NavX system in 22 AF patients, in whom 1 round of CPVA failed to disconnect 26 individual PVs (30%) in 18 patients. In these patients, a local activation map within the CPVA line (PV map) was created by a 20-pole circular mapping catheter with the use of the NavX, with 71 ± 37 sampling points per PV antrum. The conduction gap was defined as a site on the CPVA line, from which the activation proceeded toward the entire PV. The mapped PV antra were comprised of the left superior PV in 11, right superior PV in 10, left inferior PV in 3, right inferior PV in 1 and a left common PV in 1 PV(s). The conduction gaps were identified at 1.4 ± 0.7 sites per PV antrum, with an electrogram amplitude of 0.8 ± 0.7 mV. A point ablation at the gap completely isolated 24 out of 26 PV antra (92%) with 1.9 ± 1.3 applications. The PV map was useful for quickly and accurately identifying the conduction gap(s) after 1 round of CPVA.

Simultaneous, But Dissociated Left Atrial Fibrillation and Pulmonary Vein Tachycardia

A 74-year-old man with symptomatic drug-refractory persistent atrial fibrillation (AF) was referred for a catheter ablation procedure. The patient was in AF at the beginning of the procedure. As shown in Figure 1A, a decapolar catheter in the coronary sinus and a spiral mapping catheter within the ostium of the left common pulmonary vein (LCPV) demonstrated the presence of AF within both the left atrium (LA) and the LCPV, respectively. During circumferential ablation of the LCPV, the electrograms (EGMs) in the LCPV changed to an organized rhythm (mean cycle length, 178 ms) consistent with an ongoing PV tachycardia (Figure 1B). Suspecting that the LCPV was in fact isolated, the patient underwent electrical cardioversion, which terminated both the LA AF and the LCPV tachycardia (Figure 2A). PV entrance and exit block was confirmed by (1) spontaneous isolated PV potentials (Figure 2A, arrows), (2) catheter-induced AF confined solely to the LA (Figure 2B), and (3) pacing within the PV (Figure 2C). Following a second cardioversion, …

Computational Method to Predict Esophageal Temperature Elevations During Pulmonary Vein Isolation

The esophagus is in close proximity to the posterior wall of the left atrium, which renders it susceptible to thermal injury during radiofrequency (RF) ablation procedures for atrial fibrillation (AF). Real-time assessment of esophageal position and temperature (T°) during pulmonary vein (PV) isolation has not been extensively explored. To develop a protocol that allows estimation of the potential for, and avoidance of, esophageal heating. In consecutive patients who underwent PV isolation, a thermal probe was used to monitor T° fluctuations in the esophagus during application of RF energy. The tip of the thermal probe was positioned at the level of the targeted PV and RF was discontinued for T° rise >0.5°C. The proximity of individual PVs to the esophagus was measured from the temperature probe tip to the closest posterior part of the Lasso catheter from review of biplane projections (left anterior oblique 60° and right anterior oblique 30°). These raw distances were entered into the Pythagorean theorem and the actual distance between the esophageal thermal probe and PV antrum was determined. The study cohort included 44 patients (60 ± 11 years, 61% male, 57% lone AF). The thermal probe in the esophagus was closer to the left-sided PVs (left common pulmonary vein: 20.9 ± 13 mm, left upper pulmonary vein: 20.5 ± 11 mm, left lower pulmonary vein: 23.4 ± 10 mm) than the right-sided ones (right common pulmonary vein: 31.0 ± 11 mm, right upper pulmonary vein: 41.9 ± 18 mm, right lower pulmonary vein: 34.5 ± 16 mm). A T° increase >0.5° C occurred during 116/1,495 (7.8%) deliveries. A T° rise was more likely during ablation of left-sided PVs than right-sided PVs (55% vs 10%, P < 0.0001) and when RF was delivered ≤ 24 mm from the esophagus (sensitivity 91%, specificity 81%, positive predictive value 75%, and negative predictive value 93%). A thermal probe placed in the esophagus provides real-time T° monitoring and anatomic localization. A T° rise is more likely during ablation of left PVs and during RF deliveries within 24 mm of the esophageal thermal probe.

Complete congenital obstruction of a scimitar vein in an infant with severe respiratory failure

We report an infant of 3 1/2 months with complete obstruction of the venous component of the scimitar syndrome, a large atrial septal defect within the oval fossa, a common left pulmonary vein, and pulmonary hypertension. To the best of our knowledge, ours is the first description of complete congenital obstruction of a scimitar vein.

Esophageal Contour Changes during Cryoablation of Atrial Fibrillation

We have observed contour changes of the barium-filled esophagus during atrial fibrillation (AF) ablation with cryo-energy delivered in direct proximity to the esophagus. To evaluate the frequency, location, and severity of esophageal contour changes during cryo-energy application close to the esophagus. We retrospectively analyzed cine-fluoroscopic images acquired during hybrid cryo-radiofrequency AF ablation in 100 consecutive patients with cryo-energy delivered only in direct proximity to the esophagus. Esophageal contour changes were observed in 28 (32%) of 89 patients (and 74 [6.2%] of 1,191 of all cryo applications). They were more frequent in the left common pulmonary vein (PV) (50%) and less so in the right common PV and the upper PVs (4-5%). The distance of the ablation catheter from the endoesophageal contour prior to cryo-energy applications associated with contour changes was 1.8 +/- 1.5 mm, which increased to 4.1 +/- 1.6 mm at the time of peak contour change (P < 0.001). The esophageal contour deformation was 2.3 +/- 0.9 mm. There were no apparent complications related to cryo-energy application for 3-4 minutes, even if associated with contour changes. Esophageal contour changes were observed in >6% of cryo applications in direct proximity to the esophagus (32% of patients) and were most frequent in the posterior aspect of the left common and right lower PV ostium when cryo-energy was delivered at a distance of <or=5 mm from the esophageal contrast silhouette. No overt esophageal injury occurred. However, the safety of cryo-energy application in direct proximity to the esophagus remains to be further confirmed.

Constrictive Pericarditis After Catheter Ablation for Atrial Fibrillation

A 70-year-old man with paroxysmal atrial fibrillation was referred for pulmonary vein isolation. Past medical history included ischemic heart disease and a right hemicolectomy for Duke’s C carcinoma 10 years previously. Presenting ECG showed sinus rhythm with a normal axis and evidence of left atrial enlargement (Figure 1). Preoperative echocardiography demonstrated normal left ventricular structure and function. After routine single transseptal puncture, retrograde pulmonary venography was performed. This demonstrated 2 large right pulmonary veins and a left common pulmonary vein. Subsequently, an uncomplicated wide-area circumferential ablation …

Completely thoracoscopic bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation

We describe a minimally invasive surgical technique involving completely thoracoscopic bilateral pulmonary vein isolation and left atrial appendage exclusion for the treatment of atrial fibrillation. In January and February 2007, we performed nine totally thoracoscopic bilateral pulmonary vein isolations and left atrial appendage exclusions. All patients (mean age 59.7 6 8.8 years) had paroxysmal atrial fibrillation. Four patients had a history of repeated unsuccessful percutaneous catheter procedures. Magnetic resonance imaging of the pulmonary veins showed a left common trunk pulmonary vein in one patient whereas normal anatomy was observed in the other patients. All patients were operated on under general anesthesia in the supine position with both arms slightly flexed along the body. A slight tilt of the operating table without repositioning of the patient was sufficient for adequate exposure on both sides. Furthermore, in case of an urgent sternotomy, repositioning of the patient was not necessary. Three thoracoports were introduced on each side, thefirst on the midaxillary line and a second 5 cm anteriorly through the fourth intercostal space. The third port was inserted caudally of the first port through the sixth intercostal space (Figure 1). Pulmonary vein isolation was accomplished with the Lumitip dissector and the bipolar Isolator Endo ablation clamp (AtriCure, Inc, West Chester, Ohio). Isolation was confirmed with high-frequency stimulation on the pulmonary veins in case of sinus rhythm. Additional ablation was performed if isolation was incomplete. The Isolator multifunctional pen (Atricure) was used for disruption of ganglionic plexi if these were present. The presence of ganglionic plexi was determined by stimulation of the proximal part of the pulmonary veins with a high-frequency pacemaker. The left atrial appendage was excluded with a PDS Endoloop (Ethicon, Amersfoort, The Netherlands). Patients were extubated in the operation room. All patients received warfarin sodium (Coumadin) anticoagulation therapy for 6 months. Warfarin was stopped if sinus rhythm was confirmed by 24-hour Holter registration. Warfarin was continued in one patient because of a history of a cerebrovascular accident.

Abstract 2544: Pulmonary Venous Anatomy Predicts Recurrent Arrhythmia after Pulmonary Vein Antrum Isolation for Atrial Fibrillation

Background: Pulmonary Vein Antrum Isolation (PVAI) is being used with increasing frequency for the treatment of atrial fibrillation. Multi-detector computed tomography (MDCT) can be used to evaluate the complex anatomy of the left atrium and pulmonary veins to facilitate PVAI. We hypothesized that pulmonary vein anatomy, as determined by MDCT, would predict recurrent atrial fibrillation after PVAI. Methods: We evaluated consecutive patients scheduled for PVAI who underwent a CT examination of the pulmonary veins on a Philips Brilliance 64 or Siemens Sensation-64 slice MDCT scanner &lt; 3 months prior to a PVAI procedure. The number and ostial area of all pulmonary veins, indexed to body surface area, were determined by 2 independent blinded observers. Transtelephonic monitoring was performed for the first 3– 6 months after the PVAI procedure. Patients were followed at 3, 6, and 12 months with a 12-lead EKG and 48-hour Holter monitor. Results: A total of 113 patients (mean age 58±10 years; 73% male) were enrolled and followed for 12 months. A total of 445 pulmonary vein ostia were analyzed; 26% of patients had left sided pulmonary veins with a shared common ostium. The remaining patients had 2 separate left sided pulmonary veins. At the end of the 12-month follow-up, patients with two left sided pulmonary veins had a significantly increased risk of recurrent arrhythmia (34.3%) after PVAI than patients with a common left pulmonary vein (7.7%; p=0.009; OR 4.45). There was no relationship between the number of right sided pulmonary veins or total pulmonary vein ostial size and recurrent arrhythmia (582 cm 2 /m 2 in patients with recurrence vs 505 cm 2 /m 2 without recurrence (P= 0.14). Conclusion: In patients undergoing PVAI for atrial fibrillation, the presence of two left sided pulmonary veins, as determined by MDCT, is associated with an increased risk of recurrent arrhythmia at 12 months compared with patients who have a single common left pulmonary vein.

Left atrial and pulmonary vein macroreentrant tachycardia associated with double conduction gaps: A novel type of man-made tachycardia after circumferential pulmonary vein isolation

The macroreentrant tachycardia that involves the left atrium (LA) and the pulmonary veins (PVs) after atrial fibrillation (AF) ablation has not been described. To clarify the mechanism and electrophysiological characteristics of this tachycardia. Eight patients presented with recurrent regular tachycardia after the initial procedure, which consisted of two circular linear lesions around the ipsilateral PVs. Clinical tachycardia with a cycle length of 297 +/- 38 ms presented as persistent in six and paroxysmal in two patients. During tachycardia, PV activation with one-to-one conduction from the LA to the PV was found via recovered conduction gaps in the previous lesions in all patients. Three-dimensional tachycardia mapping showed a macroreentrant pattern in two and a focal pattern in six patients. In two patients, mapping demonstrated an isthmus within the left common PV in one patient and within the right-sided PVs in another patient. In the remaining six patients with focal pattern, mapping demonstrated earliest atrial activation near the right-sided PV ostium in five patients and near the left-sided PV in one patient. Entrainment mapping showed that the LA and PVs were involved in the reentrant circuit with an isthmus between the two conduction gaps in all eight patients. The tachycardias were successfully terminated with a single radiofrequency application. No AT recurred during follow-up (12 +/- 9 months) in all patients. The LA-PV macroreentrant tachycardia involves the LA, PV, and the two conduction gaps in the previous lesions. Entrainment mapping is necessary to make the diagnosis. Ablation of this tachycardia can be facilitated by closing the conduction gaps.

CT Radiographic Findings

Radio-frequency catheter ablation (RFCA) is an ever increasing modality for treating refractory atrial fibrillation. Radiologists should not only be able to interpret and convey anatomic variations of pulmonary veins and left atrium to referring electrophysiologists, but also should be aware of all the post-RFCA complications and their radiographic findings including this rare, but often fatal complication. This report describes a fatal atrio-esophageal fistula (AEF) involving a normal variant single left common pulmonary vein after transcatheter ablation. A 59-year-old man who presented to the Emergency Department (ED) with altered mental status previously complaining of fatigue and malaise. The patient underwent a total of 2 uneventful circumferential percutaneous pulmonary vein ablations for atrial fibrillation. The most recent was performed 5 weeks before admission to ED. Within hours of initial evaluation, the patient quickly deteriorated owing to overwhelming sepsis requiring both inotropic and ventilatory support. Transthoracic echocardiography within ED showed no evidence of valvular vegetation or gas bubbles in the left atrium. Computed tomography (CT) of the chest with intravenous contrast revealed findings compatible with AEF. Head CT was negative for ischemic changes or emboli. Patient underwent emergent cardiac and esophageal surgery at which point the patient later died on the operating table. Patients who present with signs and symptoms of endocarditis, and particularly with new neurologic symptom after RFCA should be promptly evaluated for AEF. In our case, radiographic findings in correlation with clinical history and high suspicion strongly suggested this rare, often fatal complication. During review of the chest CT, particular vigilance should be made to the left pulmonary vein/posterior left atrium junction at which site fistulous tracts tend to occur. Prompt diagnosis necessitates emergent cardiac and esophageal surgery to prevent rapid deterioration and death.

A Single Pulmonary Vein as Electrophysiological Substrate of Paroxysmal Atrial Fibrillation

It has been demonstrated that pulmonary veins (PVs) play an important role in initiation and maintenance of paroxysmal atrial fibrillation (AF). However, it is not clearly known whether a single PV acts as electrophysiological substrate for paroxysmal AF. This study included five patients with paroxysmal AF. All patients underwent complete PV isolation with continuous circular lesions (CCLs) around the ipsilateral PVs guided by a three-dimensional mapping system. Irrigated radiofrequency (RF) delivery was performed during AF on the right-sided CCLs in two patients and on the left-sided CCLs in three patients. The incomplete CCLs resulted in a change from AF to atrial tachycardia (AT), which presented with an identical atrial activation sequence and P wave morphology. Complete CCLs resulted in AF termination with persistent PV tachyarrhythmias within the isolated PV in all five patients. PV tachyarrhythmia within the isolated PV was PV fibrillation from the left common PV (LCPV) in two patients, PV tachycardia from the right superior PV (RSPV) in two patients, and from the left superior PV in one patient. All sustained PV tachyarrhythmias persisted for more than 30 minutes, needed external cardioversion for termination in four patients and a focal ablation in one patient. After the initial procedure, an AT from the RSPV occurred in a patient with PV fibrillation within the LCPV, and was successfully ablated. In patients with paroxysmal AF, sustained PV tachyarrhythmias from a single PV can perpetuate AF. Complete isolation of all PV may provide good clinical outcome during long-term follow-up.

Determination of the spatial orientation and shape of pulmonary vein ostia by contrast-enhanced magnetic resonance angiography

For catheter ablation of atrial fibrillation (AF), proper catheter positioning is crucial and depends on knowledge of pulmonary vein (PV) anatomy. The aim of this study was to assess PV spatial orientation and ostial shape by contrast-enhanced magnetic resonance angiography (CE-MRA). In 30 consecutive AF patients, CE-MRA was performed prior to ostial ablation. Using a centre-line technique, the PV ostium was defined perpendicular to this centre-line. Minimal and maximal ostial diameters, ostial perimeter, and angles in the anatomical frontal and transverse planes were measured. Twenty-one patients had four separate PVs. In four patients, there was a distinct right-middle PV and in five a common left common PV was found. Left-sided PV ostia were smaller and more elliptical than right-sided PVs. In the transverse plane, the ostia of both superior PVs were directed anteriorly (LS -15 +/- 13 degrees , RS -13 +/- 11 degrees ) and both inferior PV ostia were directed posteriorly (LI 23 +/- 15 degrees , RI 39 +/- 15 degrees ). In the frontal plane, both superior PV ostia pointed upwards (LS -27 +/- 14 degrees , RS -33 +/- 12 degrees ) while the inferior ostia were directed horizontally (LI 2 +/- 11 degrees , RI 3 +/- 13 degrees ). PV ostial shape and spatial orientation are variable and can be visualized adequately by CE-MRA.

Coexistence of Intracardiac Atrial Flutter and Extracardiac Fibrillation

This report describes the coexistence of fibrillatory activity limited to an isolated left common pulmonary vein trunk with typical counterclockwise isthmus-dependent right atrial flutter in a patient undergoing a pulmonary vein isolation procedure.

Anatomic substrate, procedural results, and clinical outcome of ultrasound-guided left atrial–pulmonary vein disconnection for treatment of atrial fibrillation

This report summarizes the efficacy, safety, and feasibility of intracardiac ultrasound (ICUS) and local electrographic-guided pulmonary vein (PV)-left atrial disconnection, including the isolation of common PV trunks accomplished in 170 consecutive patients with atrial fibrillation (AF). A left common PV was found in 43% of patients with AF. During a follow-up of 549 +/- 330 days after ablation, the AF-free survival rate was 80% and comparable in paroxysmal and persistent AF. PV stenosis was detected in only 1 asymptomatic patient, who required no intervention.

Assessment of pulmonary vein anatomic variability by magnetic resonance imaging: implications for catheter ablation techniques for atrial fibrillation.

Pulmonary vein (PV) isolation for atrial fibrillation (AF) currently is performed using either an ostial or an extra-ostial approach. The objective of this study was to analyze by three-dimensional (3D) magnetic resonance angiography (MRA) the anatomy of the PVs in order to detect structural variability that would impact the choice of ablation approach. Three-dimensional MRA was performed in 105 patients undergoing PV isolation. The ostial diameter, branching pattern, and PV angulation were analyzed. Fifty-nine (56%) patients had the typical pattern of 4 PVs with 4 separate ostia, 30 (29%) patients had an additional PV, and 18 (17%) patients had a left common PV trunk. In two patients, there were three right-sided veins and a common left-sided trunk, giving rise to four ostia: three on the right and one on the left. Two different populations of right middle PVs were noted: one where the additional vein projected anteriorly to drain the right middle lobe and one posterior to drain the superior portion of the right lower lobe. The average intrapatient variability in PV diameter was 7.9 +/- 4.2 mm. The PV ostium was <10 mm in 26 (25%) patients and >25 mm in 15 (14%) patients. The first branch originated 6.7 +/- 2.3 mm from the ostium. The left superior, right superior, right inferior, and left inferior PVs were found to enter the left atrium at the following angles: 32 +/- 13 degrees, 131 +/- 11 degrees, 206 +/- 16 degrees, and 329 +/- 14 degrees, respectively. Forty-nine patients (47%) had at least one funnel shaped PV. This largest PV imaging study to date demonstrates that MRA is a valuable tool that allows detection of marked intrapatient and interpatient anatomic variability of the PVs. These findings suggest that, at least in some patients, circumferential extra-ostial left atrial encirclement of the PVs may be preferable to ostial PV isolation. These findings also may have significant implications on the future development of coil- and balloon-based catheter ablation designs for AF ablation.

The common left pulmonary vein: Intracardiac ultrasound characteristics and impact upon pulmonary vein isolation

The common left pulmonary vein: Intracardiac ultrasound characteristics and impact upon pulmonary vein isolation