Pulmonary Vein Tachycardia Research Articles

Clinical characteristics and ablation outcomes of recurrent atrial tachyarrhythmia after maze operation -a multicenter study in a single city

Abstract Backgrounds Catheter ablation of atrial tachyarrhythmia after Maze operation is challenging. Methods and Results Twenty-eight cases who underwent catheter ablation of post-Maze procedure atrial tachyarrhythmia (42 sessions; 1.5 per patient) in our 5 teaching affiliate hospitals were retrospectively analyzed. Cox-IV Maze procedure and left atrial Maze were performed in 19 cases and 5 cases, respectively. Median interval between surgery and index ablation was 35 months. In total, 46 atrial tachyarrhythmias were studied. Atrial tachycardia (AT) was the most common (n=36), whereas 4 atrial fibrillation (AF) and 2 focal AT were also observed. Identified tachyarrhythmia circuits were as follows; 16 mitral AT, 9 left atrial localized reentry (4 septal, 3 posterior, 1 left atrial appendage, 1 anterior), 6 right atrial lateral incision-related AT, 5 cavo-tricuspid isthmus (CTI)-dependent AT, 3 roof-dependent AT, 2 right atrial localized reentry (1 coronary sinus (CS), 1 CTI), 2 focal AT (1 para His, 1 CS), 1 bi-atrial AT, 1 pulmonary vein tachycardia, and 1 slow-fast AVNRT (Figure 1). Termination of targeted tachyarrhythmia was confirmed in 34 sessions (81%). AT/AF recurrence free rate at 12, 24, 36 months of follow-up were 91.8%, 81.6%, and 65.3%, respectively (Figure 2). Seven cases underwent multiple sessions (2 2nd sessions, 3 3rd sessions, 2 4th sessions). In these cases, de-novo atrial tachyarrhythmias were detected. Conclusions Most of the tachyarrhythmias after Maze operation were incision/gap-related ATs, among which mitral AT and LA localized reentry were the most prevalent. Although these challenging tachyarrhythmias can be treated with the contemporary mapping techniques, de-novo tachyarrhythmias can emerge in a remote period.Maze AT Figure 1Maze AT Figure 2

Catheter Ablation for Atrial Fibrillation in Patients ≤30 Years of Age

Pulmonary vein (PV) automaticity is an established trigger for paroxysmal atrial fibrillation (PAF), making PV isolation (PVI) the cornerstone of catheter ablation. However, data on triggers for atrial fibrillation (AF) and catheter ablation strategy in very young patients aged <30 years are sparse. A total of 51 young patients (mean age 24.0 ± 4.2 years, 78.4% men) with drug-refractory PAF underwent electrophysiology (EP) study and ablation at 5 EP centers. None of the patients had structural heart disease or family history of AF. EP study induced supraventricular tachycardia (SVT) in 12 patients (n=12, 23.5%): concealed accessory pathway mediated orthodromic atrioventricular reentrant tachycardia in 3 patients, typical atrioventricular nodal reentrant tachycardia in 6 patients, left superior PV tachycardia in 1 patient, left atrial appendage tachycardia in 1 patient, and typical atrial flutter in 1 patient. In patients with induced SVTs, SVT ablation without PVI was performed as an index procedure, except for the patient with atrial flutter who received cavotricuspid isthmus ablation in addition to PVI. Remaining patients underwent radiofrequency (n=15, 29.4%) or second-generation cryoballoon-based PVI (n=24, 47%). There were no major complications related to ablation procedures. Follow-up was based on outpatient visits including 24-hour Holter-electrocardiogram at 3, 6, and 12 months after ablation, or additional Holter-electrocardiogram was ordered in case of symptoms suggesting recurrence. Recurrence was defined as any atrial tachyarrhythmia (ATA) episode >30 seconds after a 3-month blanking period. A total of 2 patients with atrioventricular nodal reentrant tachycardia, 1 with left atrial appendage tachycardia, experienced AF recurrence within the first 3 months and received PVI. After the 3-month blanking period, during a median follow-up of 17.0 ± 10.1 months, 44 of 51 patients (86.2%) were free of ATA recurrence. In the PVI group, 33 of 39 patients (84.6%) experienced no ATA recurrence. In conclusion, SVT substrate is identified in around a quarter of young adult patients with history of AF, and targeted ablation without PVI may be sufficient in the majority of these patients. PVI is needed in the majority and is safe and effective in this population.

Persistent tachycardia within isolated pulmonary veins during atrial fibrillation ablation.

During circumferential pulmonary vein (PV) isolation for ongoing atrial fibrillation (AF), distinguishing passive conduction to the pulmonary vein (PV) from rapid PV arrhythmia in the isolated PV is difficult. Hence, the purpose of this study is to investigate both the feasibility of distinguishing the PV tachycardia after circumferential PV isolation and the electrophysiological characteristics of these tachycardia. Among 178 consecutive patients who underwent circumferential PV isolation during ongoing AF, fibrillatory PV converted to a regular cycle length PV tachycardia independent of the atrial rhythm (=independent PV tachycardia) in 13 PVs among 12 (7%) patients. We classified independent PV tachycardia according to 3 different atrial rhythms: sinus rhythm (type 1, n = 2), atrial tachycardia (type 2, n = 4), and AF (type 3, n = 6). independent PV tachycardia was observed in 3 right PV and 10 left PV (P = 0.0864). There were 10 mappable independent PV tachycardia, in which 8 were focal and 2 were macroreentrant tachycardia. i-PVT can be diagnosed in a small number of patients who underwent circumferential PV isolation during AF. The main mechanism or independent PV tachycardia was focal tachycardia mainly in the left PV.

Ganglionated plexi stimulation induces pulmonary vein triggers and promotes atrial arrhythmogenecity: In silico modeling study.

BackgroundThe role of the autonomic nervous system (ANS) on atrial fibrillation (AF) is difficult to demonstrate in the intact human left atrium (LA) due to technical limitations of the current electrophysiological mapping technique. We examined the effects of the ANS on the initiation and maintenance of AF by employing a realistic in silico human left atrium (LA) model integrated with a model of ganglionated plexi (GPs).MethodsWe incorporated the morphology of the GP and parasympathetic nerves in a three-dimensional (3D) realistic LA model. For the model of ionic currents, we used a human atrial model. GPs were stimulated by increasing the IK[ACh], and sympathetic nerve stimulation was conducted through a homogeneous increase in the ICa-L. ANS-induced wave-dynamics changes were evaluated in a model that integrated a patient’s LA geometry, and we repeated simulation studies using LA geometries from 10 different patients.ResultsThe two-dimensional model of pulmonary vein (PV) cells exhibited late phase 3 early afterdepolarization-like activity under 0.05μM acetylcholine (ACh) stimulation. In the 3D simulation model, PV tachycardia was induced, which degenerated to AF via GP (0.05μM ACh) and sympathetic (7.0×ICa-L) stimulations. Under sustained AF, local reentries were observed at the LA-PV junction. We also observed that GP stimulation reduced the complex fractionated atrial electrogram (CFAE)-cycle length (CL, p<0.01) and the life span of phase singularities (p<0.01). GP stimulation also increased the overlap area of the GP and CFAE areas (CFAE-CL≤120ms, p<0.01). When 3 patterns of virtual ablations were applied to the 3D AF models, circumferential PV isolation including the GP was the most effective in terminating AF.ConclusionCardiac ANS stimulations demonstrated triggered activity, automaticity, and local reentries at the LA-PV junction, as well as co-localized GP and CFAE areas in the 3D in silico GP model of the LA.

Pulmonary Vein Tachycardia after Pulmonary Vein Isolation for Persistent Atrial Fibrillation in a Young Patient with the Dilated Right Atrium Following Surgical Repair

The substrate for atrial fibrillation (AF) in young patients with congenital heart disease could be heterogeneous. We report a 24-year old patient with persistent AF having the dilated right atrium following surgical repair of congenital heart disease demonstrating sustained pulmonary vein tachycardia (PVT) after pulmonary vein isolation. The sustained PVT could have been a major substrate for the maintenance of AF in this young patient.

Successful transbaffle catheter ablation of pulmonary vein tachycardia

A 46-year-old woman with a history of transposition of the great arteries, Mustard operation, and tricuspid valve (TV) replacement underwent catheter ablation …

The role of successful catheter ablation in patients with paroxysmal atrial fibrillation and prolonged sinus pauses: outcome during a 5-year follow-up

Although patients with paroxysmal atrial fibrillation (AF) and prolonged sinus pauses [tachycardia-bradycardia syndrome (TBS)] are generally treated by permanent pacemaker, catheter ablation has been reported to be a curative therapy for TBS without pacemaker implantation. The purpose of this study was to define the potential role of successful ablation in patients with TBS. Of 280 paroxysmal AF patients undergoing ablation, 37 TBS patients with both AF and symptomatic sinus pauses (age: 62 ± 8 years; mean maximum pauses: 6 ± 2 s) were analysed. During the 5.8 ± 1.2 years (range: 5-8.7 years) follow-up, both tachyarrhythmia and bradycardia were eliminated by a single procedure in 19 of 37 (51%) patients. Repeat procedures were performed in 14 of 18 patients with tachyarrhythmia recurrence (second: 12 and third: 2 patients). During the repeat procedure, 79% (45 of 57) of previously isolated pulmonary veins (PVs) were reconnected to the left atrium. Pulmonary vein tachycardia initiating the AF was found in 46% (17 of 37) and 43% (6 of 14) of patients during the initial and second procedure, respectively. Finally, 32 (86%) patients remained free from AF after the last procedure. Three patients (8%) required pacemaker implantation, one for the gradual progression of sinus dysfunction during a period of 6.5 years and the others for recurrence of TBS 3.5 and 5.5 years after ablation, respectively. Catheter ablation can eliminate both AF and prolonged sinus pauses in the majority of TBS patients. Nevertheless, such patients should be continuously followed-up, because gradual progression of sinus node dysfunction can occur after a long period of time.

第20回 臨床不整脈研究会 肺静脈隔離術に関連して生じた肺静脈頻拍に対するアブレーション治療と頻拍機序に関する検討

第20回 臨床不整脈研究会 肺静脈隔離術に関連して生じた肺静脈頻拍に対するアブレーション治療と頻拍機序に関する検討

211: Left atrial flutter occurring after atrial fibrillation ablation: ablation using remote magnetic navigation versus manual technique

Limited data exist on the efficacy and safety of remote magnetic navigation (RMN) ablation of iatrogenic left atrial flutter (LAF) occurring after atrial fibrillation (AF) ablation. LAF ablation procedures (proc) were reviewed. Patients (pts) were divided into 2 groups (gr): RMN gr if proc were performed remotely using the Niobe system (Sterotaxis) and conventional gr (CON) if proc were performed with manually driven catheters. Open-irrigated 3.5 mm-tip catheters were used in all pts. Activation LA maps were realized in all pts using Carto or EnSite). Acute (defined as sinus rhythm- SR- resumption during ablation) and long-term (defined as SR maintenance) proc success, proc duration, fluoroscopy and radiofrequency (RF) times, and the mechanism of arrhythmias were studied. In 46 pts (38 males, 60.8±10.19 y) 57 LAF ablation proc were performed. Age and LA size were similar. Activation maps showed: a unique macro-reentrant circuit 46%, multiples successive macro-reentrant circuits 26%, focal pulmonary vein tachycardia 9%, micro-reentrant circuit 19%. Results are showed in the table. Complications occurred in 3 proc: 1 in the RMN gr (groin hematoma) and 2 in the CON gr (1 transient ischemic attack and 1 cardiac perforation with tamponade). Perimitral flutter that occurred at any stage of the proc was associated with significantly higher rate of acute failure (persistent perimitral flutter at the end of the proc, both gr): 44% vs 12% for other types of flutter, p=0.02. RMN (n= 25) CON (n= 32) p Acute success 80% 78% 0.86 Proc/pt 1.2±0.5 1.2±0.8 0.74 Long-term success (follow-up 12.5±11.3 months) 81% 66% 0.44 Fluoroscopy 748±377 s 1086±772 s 0.05 Proc time 236±68 min 201±72 min 0.06 RF time 1291±880 s 1181±897 s 0.70 As compared to manual proc, RMN guided ablation for LAF after AF ablation provides comparable acute and long-term success rate but is potentially safer.

Pulmonary vein tachycardia during atrial tachycardia in the context of atrial fibrillation ablation

Although checking the pulmonary vein isolation (PVI) is an important first step to identify atrial tachycardia (AT) mechanism in the context of atrial …

巨大共通幹をもつ肺静脈隔離後に肺静脈内マクロリエントリー性頻拍が証明された1例

巨大共通幹をもつ肺静脈隔離後に肺静脈内マクロリエントリー性頻拍が証明された1例

Electroanatomical mapping and radiofrequency ablation of tachycardia originating in pulmonary vein in an adult patient

A 29-year-old male was admitted to our outpatient clinic because of palpitation and documented narrow QRS arrhythmia. Based on the ECG, supraventricular tachycardia was diagnosed, electrophysiological examination was indicated and ablation therapy was recommended. During positioning of the catheter the patient developed arrhythmia. On the coronary sinus catheter the activation spread from distal to proximal electrodes, suggesting left atrial origin. During atrial entrainment pacing long return cycle was observed and distal coronary sinus pacing resulted in a 15 ms longer cycle length than the arrhythmia. Therefore, the left atrial origin of the arrhythmia was confirmed and double transseptal puncture was performed. Lasso and irrigated tip catheter were introduced into the left atrium and electroanatomical mapping was performed with CARTO3 system. After electroanatomical mapping the origin of tachycardia was located proximally in the left superior pulmonary vein. Ablation was started at the earliest activation point, where acceleration was observed and the arrhythmia stopped after the first ablation. Pulmonary vein isolation was completed, and bidirectional block could be confirmed. After 30 minutes the arrhythmia was not inducible. During follow-up, Holter-examination was negative and the patient remained asymptomatic. The pulmonary vein tachycardia is a supraventricular arrhythmia that can occur at any age, but the diagnosis based on the ECG is not always simple. Detailed electroanatomical mapping is very important in the diagnosis of this type of arrhythmia, although it can be verified with conventional electrophysiological methods as well. Focal ablation may be a therapeutic option; however, total isolation of pulmonary veins can be more effective.

Reentrant Pulmonary Vein (PV) Tachycardia Was Proved after a Huge Left PV Common Trunk (LPVCT) Was Isolated

Reentrant Pulmonary Vein (PV) Tachycardia Was Proved after a Huge Left PV Common Trunk (LPVCT) Was Isolated

Two completely separated arrhythmias in one single heart chamber

A 61-year-old male patient underwent an electrophysiological study and ablation for symptomatic atypical atrial flutter which was most likely related to previous intraoperative cryoablation for treatment of paroxysmal atrial fibrillation during open heart surgery. During the procedure, a tachycardia was induced in the electrically isolated left inferior pulmonary vein (PV). With the routine induction protocol, perimitral flutter was induced, whereas, independently, the PV tachycardia was still maintained. After ablation of the mitral isthmus, no tachycardias were inducible anymore.

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, …

Acute vagal modulation of electrophysiology of the atrial and pulmonary veins increases vulnerability to atrial fibrillation

Vagal activity is thought to influence atrial electrophysiological properties and play a role in the initiation and maintenance of atrial fibrillation (AF). We evaluated the effects of acute vagal stimulation on atrial conduction, refractoriness of atrial and pulmonary veins (PVs) and inducibility of AF. An open-chest epicardial approach was performed in New Zealand White rabbits with preserved autonomic innervation. Atrial electrograms were obtained with four unipolar electrodes placed epicardially along the atria (n = 22) and an electrode adapted to the proximal left PV (n = 10). The cervical vagus nerve was stimulated with bipolar platinum electrodes (20 Hz). Epicardial activation was recorded in sinus rhythm, and effective refractory periods (ERPs), dispersion of refractoriness and conduction times from high-lateral right atrium (RA) to high-lateral left atrium (LA) and PVs assessed at baseline and during vagal stimulation. Burst pacing (50 Hz, 10 s), alone or combined with vagal stimulation, was applied to the right (RAA) and left atrial appendage (LAA) and PVs to induce AF. At baseline, ERPs were lower in PVs than in LA and LAA, but did not differ significantly from RA and RAA, and there was a significant delay in the conduction time from RA to PVs compared with the activation time from RA to LA (P < 0.01). During vagal stimulation, ERP decreased significantly at all sites, without significant differences in the dispersion of refractoriness, and the atrial conduction times changed from 39 ± 19 to 49 ± 9 ms (RA to PVs; n.s.) and from 14 ± 7 to 28 ± 12 ms (RA to LA; P = 0.01). Induction of AF was reproducible in 50% of cases with 50 Hz and in 82% with 50 Hz combined with vagal stimulation (P < 0.05). During vagal stimulation, AF cycle length decreased at all sites, and AF duration changed from 1.0 ± 0.9 to 14.0 ± 10.0 s (P < 0.01), with documentation of PV tachycardia in three cases. In 70% of the animals, AF ceased immediately after interruption of vagal stimulation. We conclude that in the intact rabbit heart, vagal activity prolongs interatrial conduction and shortens atrial and PV ERP, contributing to the vulnerability to the induction and maintenance of AF. This model may be useful in the assessment of the autonomic influence in the mechanisms underlying AF.

Isolated pulmonary vein tachycardia during atrial fibrillation

A 67-year-old man with a 5-year history of drug-refractory persistent atrial fibrillation (AF) lasting for 7 months prior to the procedure underwent radiofrequency (RF) catheter ablation. The initial AF cycle length (CL) in the coronary sinus (CS) was 162 ms. Ablation was started with isolation of the left pulmonary veins (PV) by creating a continuous linear lesion around the ipsilateral PVs in a distance of *1 cm proximally to the PV ostia. Electrical isolation was confirmed by a single circumferential mapping catheter (Lasso, Biosense-Webster, Diamond Bar, CA, USA) which was sequentially placed in the superior and inferior left PV. After electrical disconnection of the left PVs, accompanied by a slow dissociated rhythm in both PVs, isolation of the right PVs was attempted using the same technique. Initially, a long continuous circular lesion was deployed surrounding both right PVs. Afterwards, potential electrical sleeve conductions of both right PVs were specifically targeted by repeatedly replacing the Lasso catheter in the superior and inferior right vein. However, complete elimination of all PV potentials could only be achieved in the right inferior PV. In contrast, the right superior PV (RSPV) still demonstrated PV potentials with a CL shorter than CS–CL. Although a total of 18 min of RF has been applied in order to isolate the right PVs, apparently no elimination of PV potentials in the RSPV could be achieved. Since the very short CL of the RSPV (CL = 114 ms, Fig. 1) was suggestive for a driving role of this vein in the AF process, external electrical cardioversion was performed to clarify the earliest PV activation during sinus rhythm and, thereby, to facilitate electrical isolation of this potentially ‘‘culprit vein’’. However, no potentials could be demonstrated in the RSPV after cardioversion (Fig. 2). Furthermore, pacing from within the PV demonstrated RSPV exit block. Thus, this observation retrospectively reveals the presence of a persistent PV tachycardia in the electrically isolated RSPV coexisting with ongoing and independently operating AF in the atria. Since complete isolation was confirmed, AF was reinduced and the ablation procedure was continued using the stepwise ablation approach. This approach comprises PV isolation, bi-atrial defragmentation, defragmentation and/or electrical isolation of the coronary sinus and leftatrial linear ablation. The aim of the mapping and ablation process is to gradually eliminate AF sources as represented by an incremental increase of the overall AFCL resulting in AF termination either directly to sinus rhythm or to atrial tachycardia(s) which are targeted until achievement of sinus rhythm [1, 2].

Electrophysiological Characteristics of Atrial Tachycardia After Pulmonary Vein Isolation of Atrial Fibrillation

Pulmonary vein (PV) isolation is a cornerstone of atrial fibrillation (AF) ablation. This technique is now widely spread all over the world. Numerous studies have demonstrated that complete PV isolation with circular lesions has a better outcome in patients with paroxysmal and persistent AF. In contrast, it may lead to iatrogenic left atrial tachycardia (AT) as an adverse effect of the ablation. Three mechanisms of AT can develop after AF ablation, including macro-reentrant AT, focal AT and PV tachycardia. AT after AF ablation is predominantly related to the arrhythmogenicity of the PVs, lesions created by the ablation procedure and damaged atrial tissue from the persistent tachyarrhythmias. The 3-dimensional maps play an important role in clarifying the mechanism of the tachycardia and the optimal ablation site for ATs.

A unique iatrogenic organized left atrial tachycardia with a gap conduction in previously ablated lesions

This case concerns a 57-year-old woman with an organized left atrial tachycardia (AT) after pulmonary vein (PV) isolation. The left inferior PV (LIPV) exhibited a figure of eight tachycardia around the LIPV ostium with one loop at the anterior aspect and another at the posterior aspect, which corresponded to regular surface P waves. Although a gap ablation of fractionated electrograms changed the LIPV sequence, the atrial potentials were organized with a shortened cycle length accompanied by the same surface P-wave morphology. The elimination of the anterior loop and modification of the posterior loop after the gap ablation might have yielded that specific sequence change of the AT.

Maintenance of Atrial Fibrillation by Pulmonary Vein Tachycardia with Ostial Conduction Block: Evidence of an Interpulmonary Vein Electrical Connection

We report a case of a 56-year-old man with paroxysmal atrial fibrillation who underwent segmental, ostial pulmonary vein (PV) isolation while in arrhythmia. During isolation of the left superior PV (LSPV), organized electrical activity was seen within the vein, suggestive of a PV tachycardia with a cycle length of 90 ms. Simultaneously, organized electrical activity with a cycle length of 180 ms was seen in the left inferior PV (LIPV), suggestive of 2:1 conduction between the LSPV and the LIPV. Isolation of the LIPV resulted in conversion to sinus rhythm, while confirming isolation of the LSPV by the presence of ongoing PV tachycardia in this vein. This case demonstrates a direct electrical connection between the ipsilateral left PVs, leading to maintenance of atrial fibrillation.