Lower Pulmonary Vein Research Articles

High-Power (40-50 W) Radiofrequency Ablation Guided by Unipolar Signal Modification for Pulmonary Vein Isolation: Experimental Findings and Clinical Results.

Background Although proposed to facilitate pulmonary vein isolation (PVI), high-power ablation may favor extracardiac damage. Negative component abolition of the unipolar signal reflects lesion transmurality. The present study sought to evaluate the safety and efficacy of high-power ablation using unipolar signal modification as a local end point. Methods High power and standard power were compared in 4 swine and 100 consecutive patients referred for PVI. The first 50 patients were included in the control group (25-30 W) and the last 50 patients in the study group (40-50 W). Atrial radiofrequency applications were stopped 2 s (study group and swine) or 5 s (control group) after unipolar signal modification. Ventricular radiofrequency applications of 500 J (25 W·20 s versus 50 W·10 s) were performed at the swine epicardium. Results Swine gross necropsy did not show any extracardiac damage related to atrial lesions. At equal energy of 500 J, 50 W lesions were deeper (3±0.9 versus 2.6±1.1 mm; P=0.03) and wider (6.2±2 versus 5±2.3 mm; P=0.006) than 25 W lesions. No complications occurred during the clinical study, whatever the power output used for PVI. For a similar sinus rhythm maintenance at 12 months (90% versus 88%; P=0.75), the study group displayed higher first-pass PVI (92% versus 73%; P<0.001), lower acute pulmonary vein reconnection (2% versus 17%; P<0.001), reduced procedure time (73.1±18.2 versus 107.4±21.2 min; P<0.001), and ablation time (13±2.9 versus 30.3±8.8 min; P<0.001). Conclusions High-power PVI guided by unipolar signal modification safely decreases procedural burden while ensuring robust 12-month outcomes.

Thoracoscopy resection of a giant solitary fibrous tumor with double pedicles and double blood supply: a case report

BackgroundSolitary fibrous tumors are rare tumors derived from the pleura. A tumor generally has only one pedicle. Video-assisted thoracoscopic surgery is generally used when a tumor is small (< 10 cm), and traditional open surgery is often used when a tumor is large.Case presentationWe report a 49-year-old male patient with a space-occupying lesion in the right chest. Three-dimensional reconstruction showed that the blood supply to the tumor originated from the right lower pulmonary artery and vein. The patient was treated with minimally invasive surgery. Intraoperative exploration revealed that the tumor had two tumor pedicles, and each pedicle has an independent blood supply. The special bagging and extraction of the specimen were applied. The size of the specimen was 18 × 12 × 6 cm. Postoperative pathological examination revealed a solitary fibrous tumor.ConclusionsThe solitary fibrous tumor with double pedicles and double blood supply is very rare, and it has not been reported before. Preoperative three-dimensional reconstruction plays an important role in understanding the blood supply to the tumor and the location of the tumor pedicles. After careful and comprehensive evaluation, endoscopic surgery can also be applied to the treatment of the larger fibroma (> 10 cm). The larger specimen can be extracted from the smaller incision by the “pulling carrot” method.

A novel concept for evaluation of pulmonary function utilizing PaO2/FiO2 difference at the distinctive FiO2 in cellular exvivo lung perfusion-an experimental study.

For more accurate lung evaluation in exvivo lung perfusion (EVLP), we have devised a new parameter, PaO2 /FiO2 ratio difference (PFD); PFD1-0.4 = P/F ratio at FiO2 1.0 - P/F ratio at FiO2 0.4. The aim of this study is to compare PFD and transplant suitability, and physiological parameters utilized in cellular EVLP. Thirty-nine human donor lungs were perfused. At 2h of EVLP, PFD1-0.4 was compared with transplant suitability and physiological parameters. In a second study, 10 pig lungs were perfused in same fashion. PFD1-0.4 was calculated by blood from upper and lower lobe pulmonary veins and compared with lobe wet/dry ratio and pathological findings. In human model, receiver operating characteristic curve analysis showed PFD1-0.4 had the highest area under curve, 0.90, sensitivity, 0.96, to detect nonsuitable lungs, and significant negative correlation with lung weight ratio (R2 =0.26, P<0.001). In pig model, PFD1-0.4 on lower and upper lobe pulmonary veins were significantly associated with corresponding lobe wet/dry ratios (R2 =0.51, P=0.019; R2 =0.37, P=0.060), respectively. PFD1-0.4 in EVLP demonstrated a significant correlation with lung weight ratio and allowed more precise assessment of individual lobes in detecting lung edema. Moreover, it might support decision-making in evaluation with current EVLP criteria.

Atypical Mixed Total Anomalous Pulmonary Venous Connection: A Case Report

A 2 years old boy presented to us with a history of repeated respiratory tract infections and bluish discoloration of tongue, lips and figure tips for last 18 months. Echocardiography and Computed tomography (CT) angiogram revealed total anomalous pulmonary venous connection (TAPVC) mixed type (supracardiac and cardiac);all pulmonary veins drain into a common chamber behind left atrium (LA) and left lower pulmonary vein (LUPV) drains to vertical vein and common chamber both.The patient underwent rerouting of pulmonary veins and vertical vein ligation above the drainage of LUPV.&#x0D; Bangladesh Heart Journal 2018; 33(2) : 138-140

Less Pulmonary Vein Reconnection atRedo Procedures Following Radiofrequency Point-by-Point AntralPulmonary Vein Isolation WiththeUse of Contemporary CatheterAblation Technologies.

This study investigated whether real-world use of contemporary technologies changed pulmonary vein (PV) reconnection and redo pulmonary vein isolation (PVI) procedure frequencies. Previous studies consistently reported that following PVI recurrence of PV conduction is observed in >80% of patients. Consecutive patients undergoing 529 first and/or redo radiofrequency point-by-point PVI between January 2013 and December 2016 were included. Between 2013 and 2016, redo PVI rate in atrial fibrillation significantly decreased (p< 0.001); in≤12 months, first redo PVI rate decreased from 19% to 4%. The percentage of patients having PV reconnection at second PVI significantly decreased from 90% to 29% (p= 0.001). One PVI was performed in 393 and >1 in 79 patients. Female sex was associated with >1 PVI (hazard ratio [HR]: 1.86; 95% confidence interval [CI]: 1.10 to 3.13; p= 0.02). Sixty patients underwent first and second PVI in the study period. Female sex (HR: 2.79; 95% CI: 1.67 to 4.64; p< 0.001) and left atrial diameter (HR: 1.05; 95% CI: 1.01 to 1.08; p= 0.01) were associated with more and use of automatic ablation annotation algorithm during first PVI with fewer (HR: 0.54; 95% CI: 0.32 to 0.92; p= 0.02) redo PVI procedures. In 31 of 60 patients,≥1 PV was reconnected at second PVI. The need for "touch-up" applications at the first PVI was the only predictor of PV reconnection. Redo rate in atrial fibrillation and PV reconnection at redo PVI significantly decreased in recent years. Male sex, left atrial diameter, and use of automatic ablation annotation algorithm at first PVI were associated with fewerredo procedures. First-pass isolation was associated with lower PV reconnection rate at second procedure. Femalesex was associated with more redo procedures but not higher PV reconnection frequencies.

Injury of the right lower pulmonary vein by the electrocautery scalpel

Injury of the right lower pulmonary vein by the electrocautery scalpel

P2.17-26 Quantifying the Interfractional Motion of the Esophagus During Radiation Therapy for Locally Advanced Non Small Cell Lung Cancer

To quantify the interfractional motion of the esophagus during radiation therapy for locally advanced non small cell lung cancer using daily cone beam CT. The analysis of interfractional esophagus motion was performed on treatment planning 4DCT scans and daily CBCT acquired from 35 patients with stage IIIA/B NSCLC. The simulation CT and CBCT were fused using bone registries and adjusted to the carina. Interfractional motion of the esophagus in the right-left (RL) and anterior-posterior (AP) directions at levels of sternal notch (A), carina (B), 2.5 cm below the carina (C) and the left lower pulmonary vein (D) was recorded and analyzed respectively. A total of 612 CBCT image sets were obtained. The mean interfractional RL motion at level A, B, C and D was 0.5±2.9mm, -0.2±3.7mm, -0.5±3.9mm and -1.3±4.8mm, with the mean absolute value of 2.1±2.0mm, 2.7±2.6mm, 2.9±2.6mm and 3.4±3.6mm, respectively. The mean AP motion at level A, B, C and D was -0.3±2.0mm, 1.0±2.0mm, 1.3±2.2mm and 2.2±2.4mm, with the mean absolute value of 1.6±1.3mm, 1.7±1.6mm, 2.6±1.9mm and 3.4±3.6mm, respectively. Coverage of 95% of esophageal mobility requires 4.9 mm left, 4.4mm right, 3.1mm posterior and 3.7mm anterior margins at level A; 5.3 mm left, 6.5mm right, 4.5mm posterior and 1.9mm anterior margins at level B; 5.5 mm left, 7.2mm right, 4.8mm posterior, and 2.0mm anterior margins at level C; and 4.9 mm left, 7.9mm right, 6.3mm posterior, and 1.6mm anterior margins at level D. In RL and AP directions, the average of the absolute interfractional motion of the esophagus was 3.4mm or less at all the four levels. The interfractional motion was greatest at the level of left lower pulmonary vein. The absolute RL motion was greater than AP motion. These data helps to set margin for ITV for future IMRT trials to account for esophageal motion.

Distribution, diagnosis, and treatment of pulmonary sequestration: Report of 208 cases

ObjectiveThis study was performed to explore the clinical features, typing, distribution, and treatment of pulmonary sequestration (PS), with the aim of improving the awareness and treatment of this condition. MethodsClinical data regarding surgical procedures, outcomes, and prognosis of 208 pediatric patients with PS who were treated in our center from January 2005 to October 2017 were retrospectively analyzed. ResultsPS was confirmed by ultrasonography, enhanced computed tomography (CT), and/or magnetic resonance imaging (MRI) before surgery, and the surgeries were smoothly performed in all 208 patients (138 males, 70 females; age, 1 month to 14 years; mean age, 19.70 ± 48.82 months). The operative time ranged from 10 to 230 min (mean, 70 ± 48.75 min), and the intraoperative blood loss volume ranged from 1 to 200 ml (mean, 5 ± 18 ml). PS was located in multiple sites of the thoracic cavity and was also found in some rare locations such as the neck and abdomen. The feeding arteries of the PS mainly arose from the thoracic aorta or abdominal aorta, and a few of them originated from other vessels in the systemic circulation. The venous drainage differed between intralobar and extralobar PS: in patients with intralobar PS, the venous drainage was mainly via the pulmonary veins, especially the lower pulmonary veins; in patients with extralobar PS, the venous drainage was via the azygos vein and hemiazygos vein or reached the right atrium via the vena cava. The infection rate in children with intralobar sequestration was 71.17% (79/111), and that in children with extralobar sequestration was 31.37% (16/51). ConclusionPS has increasingly been detected by prenatal ultrasonography, and enhanced CT and MRI are the main techniques for diagnosing PS. Once confirmed, PS should be surgically resected. We choose an age of 6 to 12 months for surgical resection. Minimally invasive video-assisted thoracic surgery has many advantages in the treatment of PS and can be the treatment of choice for this condition. Type of studyTreatment Study. Level of evidenceLevel III.

Pulmonary vein orientation is independently associated with outcomes following cryoballoon-based atrial fibrillation ablation

AimsSeveral studies have investigated the influence of pulmonary vein (PV) anatomy on outcomes of atrial fibrillation (AF) ablation. We aimed to evaluate the relationship between PV orientation and AF-free survival following cryoablation. Methods160 patients scheduled for cryoablation between September 2012–March 2014 were included. Patients underwent a pre-procedural cardiac CT scan with retrospective ECG gating. PV orientation was assessed according to the position of the PV orifice relative to the sagittal plane with reference to coronal and horizontal planes. Results160 patients (57 ± 9 years, 54% male, 33% persistent AF) were included and followed for a median of 17 (12–36) months. Excluding a blanking period of 3 months, freedom from AF after a single ablation procedure was 76%. Ventral-caudal left upper PV (p = 0.044) and ventral-caudal left lower PV orientation (p = 0.001) were more common in patients with AF recurrence. In multivariate Cox regression analysis, only left lower PV orientation [particularly dorsal-caudal (HR: 3.447, 95% CI: 1.180–10.070, p = 0.024) and ventral-caudal (HR: 3.391, 95% CI: 1.088–10.571, p = 0.035) orientations compared to dorsal-cranial orientation] as well as LA diameter (HR: 3.420, 95% CI: 1.809–6.465, p < 0.001) were significantly associated with AF recurrence. ConclusionThis is the first study to demonstrate the impact of PV orientation on prediction of AF recurrence following cryoablation. Preprocedural assessment of PV orientation may modify operator preferences on treatment strategies in AF.

Germ cell tumour presenting as left atrial mass

A 33-year-old male presented with dry cough for 6 months and dyspnea on exertion for 3 months for which he was treated symptomatically by nearby physicians. On two-dimensional echocardiography, it revealed large left atrial mass occupying 2/3rd of the left atrium (LA) extending into the left lower pulmonary vein (PV). Then, his computed tomography of the chest was done, which revealed posterior mediastinal mass invading the left upper and lower lobe of the lung through the left main bronchus. The lesion also invaded the LA through the left PV. Biopsy was suggestive of nonseminomatous germ-cell tumor. This case is presented to demonstrate uncommon cardiac manifestations of secondary spread of testicular malignancy.

Clamp Ablation of Pulmonary Veins During Minimally Invasive Aortic Valve Replacement

Here, we demonstrate bilateral pulmonary vein isolation using a bipolar clamp but without atriotomy during minimally invasive aortic valve replacement. The operation was performed through a right anterolateral minithoracotomy. The right pulmonary veins were ablated by using a radiofrequency clamp on the beating heart. After cardiac arrest, the ascending aorta was pulled up using umbilical tape passed through the transverse sinus. Appendage resection offered fine exposure around the lower pulmonary vein. The bipolar clamp was introduced into the oblique sinus under the aorta, and the left pulmonary veins were ablated. Finally, aortic valve replacement was performed in a standard manner.

Right lower lobectomy: section of lower pulmonary arteries, lower pulmonary vein and lower bronchus

Right lower lobectomy: section of lower pulmonary arteries, lower pulmonary vein and lower bronchus

Left lower lobectomy: section of lower pulmonary arteries, lower pulmonary vein and lower bronchus

Left lower lobectomy: section of lower pulmonary arteries, lower pulmonary vein and lower bronchus

Pulmonary Venous Infarction Secondary to Pulmonary Venous Stenosis

SESSION TITLE: Pulmonary Vascular Disease SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Tuesday, October 31, 2017 at 04:30 PM - 05:30 PM INTRODUCTION: The etiology for hemoptysis and new pulmonary opacities in an immunocompromised host can be difficult to ascertain and may require an exhaustive workup. Pulmonary venous stenosis is an uncommon cause of hemoptysis due to pulmonary infarction. CASE PRESENTATION: A 51-year-old male with Crohn's disease and radiofrequency ablation (RFA) for atrial fibrillation five months prior presented with fever and hemoptysis while on Vedolizumab and Clopidogrel. Chest CT angiography (CTPA) showed multifocal left upper lobe (LUL) opacities and ipsilateral pleural effusion with no evidence of pulmonary embolism (Image 1). Bronchoscopy and thoracentesis were non-diagnostic for infection, malignancy, and other inflammatory lung diseases. Video assisted thoracoscopic biopsy of the LUL revealed venous infarcts associated with edema and fibrosis of interlobular septa (Image 2). Expert reassessment of initial CTPA found thrombosis of the left upper lobe pulmonary vein and a filling defect of the left lower lobe pulmonary vein, which were confirmed with subsequent dedicated CT coronary angiography which showed complete occlusion of superior left pulmonary vein and significant stenosis of the left inferior pulmonary vein. DISCUSSION: The differential for pulmonary venous stenosis includes congenital stenosis, neoplasm, mediastinal mass, granulomatous disease, and less commonly RFA for atrial fibrillation secondary to thermal injury at the veno-atrial junction. The incidence of pulmonary venous stenosis with RFA is 30-40%, most often without clinical manifestations [1]. Only 0.29% of cases require intervention such as angioplasty with or without stenting [2]. When pulmonary venous stenosis is suspected, diagnostic imaging modalities including ventilation-perfusion scintigraphy, and venography (CT or MR) can be useful for confirmation. CONCLUSIONS: Symptomatic pulmonary venous stenosis secondary to RFA is uncommon, and can be difficult to identify as the cause of hemoptysis and pulmonary infarction in immunocompromised patients where other common entities are more strongly considered. Reference #1: Braun S, Platzek I, Zopheel K, Weise M, Kolditz M, Halank M, Hoeffken G. Haemoptysis due to pulmonary venous stenosis. European Respiratory Journal 2014; 170-179. Reference #2: Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ. Arrhythm. Electrophysiol. 2010 Feb;3(1):32-8. DISCLOSURE: The following authors have nothing to disclose: Tyson Sjulin, Michael Morris, Teri Franks, David Ferraro No Product/Research Disclosure Information

Temperature-Controlled Radiofrequency Ablation for Pulmonary Vein Isolation in Patients With Atrial Fibrillation

BackgroundSaline irrigation improved the safety of radiofrequency (RF) ablation, but the thermal feedback for energy titration is absent. ObjectivesTo allow temperature-controlled irrigated ablation, a novel irrigated RF catheter was designed with a diamond-embedded tip (for rapid cooling) and 6 surface thermocouples to reflect tissue temperature. High-resolution electrograms (EGMs) from the split-tip electrode allowed rapid lesion assessment. The authors evaluated the preclinical and clinical performance of this catheter for pulmonary vein (PV) isolation. MethodsUsing the DiamondTemp (DT) catheter, pigs (n = 6) underwent discrete atrial ablation in a temperature control mode (60°C/50 W) until there was ∼80% EGM amplitude reduction. In a single-center clinical feasibility study, 35 patients underwent PV isolation with the DT catheter (study group); patients were planned for PV remapping after 3 months, regardless of symptomatology. A control group included 35 patients who underwent PV isolation with a standard force-sensing catheter. ResultsPorcine lesion histology revealed transmurality in 51 of 55 lesions (92.7%). In patients, all PVs were successfully isolated; no char or thrombus formation was observed. Compared with the control group, the study cohort had shorter mean RF application duration (26.3 ± 5.2 min vs. 89.2 ± 27.2 min; p < 0.001), shorter mean fluoroscopic time (11.2 ± 8.5 min vs. 19.5 ± 6.8 min; p < 0.001), and lower acute dormant PV reconduction (0 of 35 vs. 5 of 35; p = 0.024). At 3 months, 23 patients underwent remapping: 39 of 46 PV pairs (84.8%) remained durably isolated in 17 of these patients (73.9%). ConclusionsThis first-in-human series demonstrated that temperature-controlled irrigated ablation produced rapid, efficient, and durable PV isolation. (ACT DiamondTemp Temperature-Controlled and Contact Sensing RF Ablation Clinical Trial for Atrial Fibrillation [TRAC-AF]; NCT02821351)

The limitation of transthoracic echocardiography in diagnosing partial anomalous pulmonary venous drainage

Objective: To improve the diagnostic accuracy of transthoracic echocardiography (TTE) by analyzing its limitations in diagnosing partial anomalous pulmonary venous drainage (PAPVD). Method: This was a retrospective analysis of PAPVD patients seen at the Children's Hospital of Fudan University from October 1 2006 to October 1 2016. The echocardiographic data were compared to findings on multi-slice spiral CT (MSCT), cardiac catheterization or surgery. The echocardiography machines used were Philip IE33, GE Vivid 7 and Vivid i with frequency ranging from 5.0 MHz to 7.5 MHz. The cardiac structure was analyzed according to Van Praagh segments. Result: A total of 43 cases of PAPVD were enrolled, male∶ female ratio 20∶23 with average age (27.9±21.4) months. Among them, 3 cases were simple PAPVD and 40 cases had other associated congenital heart diseases. TTE was successful in diagnosing 29 cases (67%) while 14 cases were missed. The diagnostic rate for right pulmonary vein drainage into superior vena cava, right atrium, inferior vena cava were 5/10, 17/20, and 3/5 respectively while left pulmonary vein drainage into left innominate vein was only 1/4. Added TTE images to re-exam the 9 of the 14 missed cases, 5 cases of abnormal drainage from right superior pulmonary vein were diagnosed, while 4 cases of drainage from right lower or left pulmonary vein were only picked up by indirect signs. Conclusion: The distance of the pulmonary veins from the routine ultrasound view and the possibility of branch number variation may limit the accuracy of TTE in diagnosing PAPVD, especially for drainage from right lower and left pulmonary vein. But TTE is still the preferred diagnostic method. The diagnostic rate could be increased by paying special attention to non-routine views including the suprasternal fossa, the right parasternal and subcostal area.

Sometimes Surgery is the Only Way to Make a Diagnosis and Treat the Patient: A Case of Congenital Partial Absence of Pericardium.

IntroductionA 47-year-old Caucasian woman with a past medical history of multiple ablative procedures for supraventricular arrhythmias and pacemaker implantation presented with increasing shortness of breath. The initial working diagnosis of the team treating her was ablation-induced pulmonary stenosis, especially after the recording of increased flow velocities through the right lower pulmonary vein.Case presentationThe patient was alert and oriented, but obviously dyspnoeic. The vital signs were normal. The physical examination revealed a soft cardiac systolic murmur and the lungs were clear on auscultation. The electrocardiogram showed a pacemaker rhythm. The echocardiogram showed borderline normal global systolic function of the left ventricle and severe mitral regurgitation. The transoesophageal echocardiogram confirmed the above findings and revealed increased velocities through the right lower pulmonary vein. The working diagnosis of ablation-induced pulmonary stenosis was reinforced by the cardiac CT angiography. The patient was subsequently referred for surgical intervention. The intra-operative findings were both unexpected and impressive: congenital partial absence of the pericardium was responsible for herniation of the right chambers into the pleural space. Mitral regurgitation was attributed to failure of coaptation due to the very short surface of the leaflets. Extensive external fibrosis around the pulmonary veins caused the pulmonary vein stenosis.ConclusionThe final diagnosis of a partial pericardial defect causing torsion and distortion of the heart chambers was made only at surgery. The consistent finding of pulmonary vein stenosis in the non-invasive modalities and the past medical history of ablations initially misleadingly led us to the assumption that they were related.LEARNING POINTSThe initial working diagnosis of ablation-induced pulmonary vein stenosis based on the patient’s shortness of breath, severe mitral regurgitation, right lower pulmonary vein stenosis and past medical history of multiple ablative procedures, was incorrect.The finding that the cardiac silhouette was borderline displaced to the right, the mildly hypoplastic right lung and the borderline impairment of the global systolic function of the left ventricle, especially after coronary artery disease was ruled out, should have been given greater consideration.Cardiac computer tomographic images taken 7 years ago were used to assess the severity of the right inferior pulmonary vein stenosis; new medical technologies will provide even better diagnostic techniques.

SPECKLE-TRACKING INTRACARDIAC ECHOCARDIOGRAPHY IN ATRIAL FIBRILLATION PATIENTS DURING RADIOFREQUENCY ISOLATION OF PULMONARY VEINS

Aim. To evaluate the speckle-tracking echocardiography (STE) application in atrial fibrillation (AF) patients during catheter treatment, by the data from intracardiac echocardiography (ICE). Material and methods. Totally, 30 patients included, with persistent and paroxysmal AF. In 25 (84%) the main disease was arterial hypertension, of those 14 (46%) had hypertension together with coronary heart disease. In 16% cases (4 patients) AF was idiopathic. All patients had indications for catheter treatment of the arrhythmia. Results. Before the start of radiofrequency intervention (RFI), superior pulmonary vein (PV) deformation was 24,5±1,5%, after the intervention 17,5±1,1%, tissue deformation decreased by 7% (р<0,001); of the left inferior PV before RFI — 21,5±0,9%, after — 14,4±0,9%, tissue deformation decreased by 7,1% (р<0,001); right inferior PV before RFI — 21,2±1,3%, after — 14,9±1,1%, tissue deformation decreased by 6,2% (р<0,001); right inferior before RFI — 20,5±1,1%, after — 14,4±1,1%, deformation change 6,1% (р<0,001). Under the influence of RFI, velocity of upper PV deformation decreased by 8,1% (р<0,001), to -5,36±0,5%, after — 4,93±0,35%; in lower inferior PV decrease of velocity by 8,3% (р<0,001), before RFI -5,38±0,6%, after — 4,93±0,55%; right superior PV — decrease of PV deformation by 8,5% (р<0,001), before RFI -5,5±0,15%, after -5,0±0,33%; in right inferior 8,2% (р<0,001) before RFI -5,9±0,4%, after -5,4±0,4%. Conclusion. Decrease of deformation by more than 6% and velocity of deformation by 8% after radiofrequency intervention are relevant signs of pulmonary veins ostia isolation.

Pulmonary vein obstruction after catheter ablation in a patient with partial anomalous pulmonary vein connection

A 75-year-old man with symptomatic atrial fibrillation was referred to our hospital for catheter ablation. Preprocedural echocardiogram showed mild-moderate degree mitral regurgitation (MR) and mild tricuspid regurgitation (TR) with transvalvular peak gradient (TVPG) of 27mmHg. The complete isolation of the pulmonary veins was performed by radiofrequency ablation, and the patient was kept in sinus rhythm after the procedure. However, the exertional dyspnea had gradually developed one year after the procedure. Echocardiogram showed severe TR with TVPG 60mmHg. MDCT showed partial anomalous pulmonary vein connection (PAPVC) of the left upper pulmonary vein and the occlusion of left lower pulmonary vein ostium: pulmonary venous flow of the left upper lung was drained into the brachiocephalic vein. The patient underwent surgical correction of PAPVC and annuloplasty of the mitral and tricuspid valve. Although it is unclear whether there is direct causal relationship between PAPVC and PV obstruction, anatomical evaluation of PVs is important in patients undergoing catheter ablation.<Learning objective: Partial anomalous pulmonary vein connection (PAPVC) is rare and often asymptomatic in adults. In the present case, pulmonary vein obstruction occurred after radiofrequency catheter ablation in a patient with PAPVC. Although pulmonary venous flow from only left upper lobe drained into the brachiocephalic vein before ablation, occlusion of the left lower pulmonary vein resulted in right heart failure one year after ablation.>

Spatial distribution of electrical reconnection after pulmonary vein isolation in patients with recurrent paroxysmal atrial fibrillation.

IntroductionRecurrence of atrial fibrillation after pulmonary vein isolation (PVI) occurs frequently and may be associated with electrical reconnection of the pulmonary veins (PV). We investigated spatial distribution of electrical reconnection during re-do procedures in patients with paroxysmal atrial fibrillation who had previous successful acute electrical PVI with either single irrigated tip, antral ablation (s-RF; n = 38) or multi-electrode, duty-cycled ablation (PVAC; n = 48).Methods and ResultsEP navigator, mapping and irrigated tip ablation catheters were used in all re-do procedures. Sites of reconnection were assessed in a 12-segment model. Baseline clinical and demographic characteristics were similar in both groups. The number of PVs reconnected per patient was similar in both groups (2.9 ± 0.9 and 3.2 ± 0.7 (p = 0.193), s‑RF and PVAC, respectively), and each PV was equally affected. However, the inferior quadrant of the right lower PV was significantly more vulnerable to reconnection after previous PVAC ablation, whereas the superior quadrant of the right upper PV showed significantly more reconnection in the s‑RF group.ConclusionThe overall number of PVs reconnected was equally high in both groups, and each PV was affected equally. However, there were significant differences in the spatial distribution of electrical reconnection. Better understanding of predilection sites for reconnection might help to improve the long-term success rate of PVI.