Variations Of Pulmonary Veins Research Articles

Novel cryoballoon technology for atrial fibrillation ablation: Impact of pulmonary vein variant anatomy, cooling characteristics, and 1-year outcome from the CHARISMA registry

BackgroundNo data have been reported on cooling characteristics and the impact of variant pulmonary vein (PV) anatomy on atrial fibrillation (AF) recurrences after POLARx cryoballoon (CB) ablation. ObjectiveThe purpose of this study was to analyze the impact of PV anatomy variants and cooling characteristics after CB ablation from a large multicenter prospective registry. MethodsThe primary end point was defined as 1-year absence of any atrial tachyarrhythmias (ATAs: AF/atrial flutter/atrial tachycardia). Correlation between ATA recurrences and anatomy variants/cooling characteristics were evaluated. The secondary outcome was the rate of major periprocedural complications. ResultsA total of 429 consecutive patients diagnosed with paroxysmal AF (83.4%) or persistent AF (peAF; 16.6%) were enrolled. Twenty-eight patients (6.6%) exhibited an anatomical variant (common ostium: 4.0%; adjunctive PV: 2.6%). Nadir temperature, thaw time, and total deflation time were different between standard PVs and PV variants. After the blanking period, over a mean of 431 ± 99 days of follow-up, 63 patients (14.7%) suffered an ATA recurrence. Patients with recurrences had both a shorter thaw time (18.5 ± 7 seconds vs 19.8 ± 7 seconds; P = .0012) and a shorter total deflation time, whereas time to isolation was longer (57.4 ± 42 seconds vs 49.1 ± 33 seconds; P = .04). Patients with anatomy variants showed a similar ATA recurrence rate (5 of 28 [17.9%]) to the standard PV anatomy group (58 of 401 [14.5%]) (P = .584), with a hazard ratio (HR) of 1.43 (95% confidence interval [CI] 0.49–4.13; log-rank, P = .4384). After adjusting for confounders, heart failure (HR 4.12; 95% CI 1.75–9.73; P = .0013) and peAF (HR 1.81; 95% CI 1.03–3.18; P = .0433) remained associated with ATA recurrence during follow-up. ConclusionThe POLARx CB system demonstrated long-term efficacy, along with a safe profile, in both patients with paroxysmal AF and those with peAF, regardless of the presence PV variants. Time to isolation was longer in patients with ATA recurrences during follow-up. Clinical Trial RegistrationCatheter Ablation of Arrhythmias with a High-Density Mapping System in Real-World Practice (CHARISMA). ClinicalTrials.gov identifier: NCT03793998. Registration date: January 4, 2019.

Impact of pulmonary vein variant anatomy during cryo-ablation in paroxysmal and persistent AF patients: 1-year outcome from a nationwide multicenter clinical setting

Abstract Background Complete electrical pulmonary vein isolation (PVI) by cryo-balloon approach is a well-established ablation strategy of atrial fibrillation (AF). While contrast findings exist regarding the influence of variant pulmonary vein (PV) anatomy on predicting AF recurrence, limited data are currently available specifically for cases involving the POLARx cryoablation system during PVI. Purpose We report the real-world experience of POLARx in the context of de novo AF ablation in a multicenter Italian registry. Methods Consecutive patients undergoing AF ablation from the CHARISMA registry at 10 Italian centres were included. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred >60 sec or when time to isolation was not available. The ablation endpoint was PVI as assessed by entrance and exit block. All patients were followed-up for at least 12 months after the procedure. Results Four-hundred twenty-nine patients were included (n=358, 83.4% paroxysmal AF, n=71, 16.6% persistent AF, mean age 60.7±10 years, 28.3% female, mean LVEF 58±8%). PVI was achieved in all pts using only cryoablation. Twenty-eight (6.6%) patients exhibited an anatomical variant: 17 (4.0%) a common ostium and 11 (2.6%) an adjunctive PV. The mean number of freeze applications per patient was 5.1 (1.2 for LSPV, 1.3 for LIPV, 1.2 for RSPV and 1.3 for RIPV). Over a median of 398[370-461] days of follow-up, 14 (3.2%) patients experienced an early recurrence of AF during the 90-day blanking period. Overall, 63 patients (14.7%) suffered an AF recurrence after the 90-day blanking period (median time to recurrence 342[171-381] days). The proportion of patients exhibiting AF/AT recurrences was higher in the persistent AF group (17 out 71, 23.9%) than in the paroxysmal AF group (46 out 358, 12.8%, p=0.026), with a hazard ratio of 2.02 (95%CI: 1.2 to 3.5, p=0.0137) whereas patients with anatomy variant showed a similar AF/AT recurrence rate (5 out 28, 17.9%) than in the standard anatomy group (58 out of 401, 14.5%) with a hazard ratio of 1.43 (0.6 to 3.6, p=0.441). Four (0.9%) transient phrenic nerve palsy were observed, both with full recovery in the 48-h post procedure; no major procedure-related adverse events were reported. Conclusion In this multicenter study, the cryo-balloon system demonstrated safety and efficacy in treating both paroxysmal and persistent AF patients, yielding a low incidence of AF/AT recurrence during follow-up, regardless of the presence of variant PV anatomy.

Correlation Analysis of Pulmonary Vein Anatomy and Paroxysmal Atrial Fibrillation Recurrence after Cryoballoon Ablation

Background: Cryoballoon ablation (CBA) is a reliable therapy for paroxysmal atrial fibrillation (pAF). However, the relatively high recurrence rate poses a perplexing challenge for clinicians; thus, a more detailed understanding of the pulmonary vein anatomy and the left atrial (LA)-pulmonary vein (PV) conjunction mode is needed. This study aimed to explore the correlation between the PV anatomy and pAF recurrence in patients who underwent the index CBA. Methods: We included 274 consecutive pAF patients (men: 60%, mean age: 58.8 ± 11.5 years, median AF history: 25 (8, 63) months) with pAF who underwent their first cryoballoon ablation between October 2019 and March 2022. All data were collected from the patient’s medical records. Subsequent post-procedural long-term follow-up and statistical analysis were conducted. Results: Amongst the total patients, 220 (80%) remained AF-free. Multivariate analysis showed that the right inferior PV (RIPV) vertical angle (hazard ratio (HR): 1.097, 95% CI: 1.071–1.124, p < 0.001) and PV variation (HR: 1.905, 95% CI: 1.079–3.362, p = 0.026) correlated with postoperative AF recurrence. The study investigated the effectiveness of the RIPV vertical angle, either alone or in combination with other recognized factors. Conclusions: In patients with pAF who underwent the index CBA, the RIPV vertical angle and PV variation served as reliable prognostic predictors. Specifically, the RIPV vertical angle, either alone or in combination with recognized factors, demonstrated effective predictive performance.

Robotic-assisted right upper lobectomy with systemic pulmonary vein anomaly: a case report

BackgroundWhile the role of low-dose computed tomography (CT) in lung cancer screening is established, its limitations in detailing pulmonary vascular variations are less emphasized. Three-dimensional reconstruction technology allows surgeons to reconstruct a patient’s bronchial and pulmonary vascular structures using CT scan results. However, low-dose CT may not provide the same level of clarity as enhanced CT in displaying pulmonary vascular details. This limitation can be unfavorable for preoperative detection of potential pulmonary vascular variations, especially in cases involving planned segmentectomy.Case PresentationWe report a case of a 58-year-old female with lung cancer, initially planned for Da Vinci robot-assisted thoracoscopic segmentectomy. Unexpectedly, during surgery, a pulmonary vein variation in the right upper lobe was discovered, leading to a change in the surgical method to a lobectomy. The patient had four variant right upper lobe veins draining into the superior vena cava and one into the left atrium. The surgery was complicated by significant bleeding and postoperative pulmonary congestion. Postoperative pathology confirmed adenocarcinoma.ConclusionsThis case highlights the importance of meticulous intraoperative exploration, particularly in cases involving planned segmentectomy, as unexpected pulmonary vein variations can significantly affect surgical decision-making. While three-dimensional reconstruction based on preoperative CT data is a valuable tool, it may not capture the full complexity of the anatomical variations. We discuss potential preoperative imaging techniques, including contrast-enhanced CT and CT angiography, as methods to better identify these variations. The enhanced visualization provided by robot-assisted surgery plays a crucial role in identifying and adapting to these variations, underscoring the advantages of this surgical approach. Our report contributes to the existing literature by providing a detailed account of how these principles were applied in a real-world scenario, reinforcing the need for surgical adaptability and awareness of the limitations of low-dose CT in complex cases.

Impact of pulmonary vein anatomy and left atrial size on postoperative atrial fibrillation after esophagectomy for esophageal cancer.

This study aimed to investigate the relationship between postoperative atrial fibrillation (POAF) after esophagectomy and pre-existing cardiac substrate. We retrospectively analyzed 212 consecutive patients from between July 2010 and December 2022 who were scheduled to undergo esophagectomy for esophageal cancer without previous history of atrial fibrillation. All the patients underwent both echocardiography and contrast-enhanced multi-detector computed tomography (MDCT). POAF occurred in 49 patients (23.1%). Multivariable logistic analysis demonstrated that independent predictors for POAF were age [OR; 1.06 (1.01-1.10), P < 0.01), three-field lymph node dissection [OR; 2.55 (1.25-5.23), P < 0.01), left atrial dilatation (> 35mm) assessment by echocardiography [OR; 3.05 (1.49-6.25), P < 0.01) and common left pulmonary vein [OR; 3.03 (1.44-6.39), P < 0.01). The correlation coefficient was high for left atrial dimensions assessed by echocardiography and MDCT (r = 0.91, P < 0.01). Combination of left atrial dilatation by echocardiography and common left pulmonary vein had high odds ratio [OR; 8.10 (2.62-25.96), P < 0.01). Instead of echocardiographic assessment, combination of left atrial enlargement (> 35mm) assessed by MDCT and common left pulmonary vein also showed high odds ratio for POAF [OR; 11.23 [2.19-57.63], P < 0.01). Incidence of POAF after esophagectomy was related to both left atrial enlargement and common left pulmonary vein assessed by preoperative MDCT. Additional analysis of atrial size and pulmonary vein variation would facilitate preoperative assessment of the risk of POAF, but future studies must ascertain therapeutic strategy.

Left common trunkus pulmonary veins have genetic background and poor rhythm outcome after atrial fibrillation catheter ablation

Abstract Funding Acknowledgements Type of funding sources: None. Background There is a genetic background in pulmonary vein (PV) development and atrial fibrillation (AF). However, the genetic trait of PV variations and their rhythm outcome after AF catheter ablation (AFCA) is unclear. Objective We explored the genetic and clinical characteristics and long-term rhythm outcomes of AF patients with PV variation or left common trunkus (LCT)-PV. Methods We included 2,897 AF patients (74.0% male, age 59.0 ± 10.7 years, 66.3% paroxysmal AF) with available genome-wide association study results, cardiac computed tomogram data, and protocol-based regular rhythm follow-up from the Yonsei AF ablation cohort database. We defined LCT-PV when the upper and lower PV separate at &amp;gt;10 mm distal to the left PV antrum margin. PV variations included both LCT-PV and accessory PVs. We analyzed the polygenic risk score (PRS) of 12 AF-associated genes (DSP, GJA1, HCN4, KCNQ1, NPPA, PITX2, RYR2, SCN5a, SHOX2, ATP2A2, TBX3, and TBX5) and long-term rhythm outcomes after AFCA. Results We found PV variation in 296 (10.2%) and LCT-PV in 102 (3.5%). PRS of 1,227 single nucleotid polymorphisms (SNPs) was significantly higher in PV variation patients (p=4.93e-08) and LCT-PV patients (p=1.95e-20). The patients with LCT-PV had higher CHA2DS2VASc scores (p=0.024) and lower atrial epicardial adipose tissue volume (p=0.034). During 39.7 ± 34.8 months follow-up period, LCT-PV patients had a significantly higher recurrence rate than their counter part in the paroxysmal AF sub-group (Log-rank p=0.036), but not in overall PV variations. LCT-PV with the highest 10% PRS was independently associated with AF recurrence after AFCA (HR 2.10, 95% CI 1.21-3.63, p=0.008). Conclusions Among the patients who underwent AFCA, PV variation, including LCT-PV, has a significant genetic background. The post-AFCA recurrence rate was significantly higher in patients with LCT-PV and high PRS, especially in paroxysmal AF.

Impact of pulmonary vein anatomy and ostial dimensions on long term outcome after single-shot device guided cryoablation for paroxysmal atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Cryoballoon (CB)-guided pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). Purpose Assessment of the role of individual anatomical characteristics to predict long-term freedom from arrhythmia recurrence after CB-guided PVI for paroxysmal AF (PAF). Methods 353 consecutive patients (58±11 years, 56% males), undergoing PVI between 2012 and 2018 were analysed. Individual pulmonary vein (PV) anatomy was assessed using preprocedural cardiac magnetic resonance imaging (MRI). The impact of PV characteristics and CSA on long-term AF-free survival was evaluated. Results Acute PVI was achieved in all patients. 223 patients (63%) had a normal PV anatomy. Variant PV anatomy was present in 130 patients (37%). During the observation period of 48 months AF-recurrence was documented in 167 patients (47 %). Patients with AF-recurrence presented with significantly enlarged right-sided PVs and left superior PVs (LSPVs) (p&amp;lt;0.001). The presence of left common PVs (LCPVs) (n=75, Log-rank p&amp;lt;0.001) as well as right variant PVs (n=35, Log rank p&amp;lt;0.001) was associated with a significantly worse long-term AF-free survival rate compared to patients with normal PV characteristics. Conclusion Variant PV anatomy predicted long-term AF-recurrence. Preprocedural imaging may help to improve patients’ selection for single-shot device guided PVI.

Impact of pulmonary vein anatomy and ostial dimensions on long-term outcome after single-shot device–guided cryoablation for paroxysmal atrial fibrillation

BackgroundCryoballoon (CB)-guided pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). This observational study aimed to assess the role of individual anatomical characteristics to predict long-term freedom from arrhythmia recurrence after CB-guided PVI for paroxysmal AF (PAF).MethodsThree hundred fifty three consecutive patients (58 ± 11 years, 56% males), undergoing PVI between 2012 and 2018 were analysed. Individual pulmonary vein (PV) anatomy was assessed using preprocedural cardiac magnetic resonance imaging (MRI). For each PV, the cross-sectional area (CSA) was calculated. The impact of PV characteristics and CSA on long-term AF-free survival was evaluated.ResultsAcute PVI was achieved in all patients. Two hundred twenty-three patients (63%) had a normal PV anatomy (2 left- and 2 right-sided PV). Variant PV anatomy was present in 130 patients (37%). During the observation period of 48 months, AF-recurrence was documented in 167 patients (47 %). Patients with AF-recurrence presented with significantly enlarged right-sided PVs and left superior PVs (LSPVs) (p < 0.001). The presence of left common PVs (LCPVs) (n = 75, Log-rank p < 0.001) as well as right variant PVs (n = 35, Log rank p < 0.001) was associated with a significantly impaired long-term AF-free survival rate as compared to patients with normal PV characteristics.ConclusionVariant PV anatomy is a good predictor for AF-recurrence. A correlation between an enlarged CSA of right-sided PVs as well as LSPVs and AF-recurrence was documented.

Comparison of pulmonary veins in patients with and without atrial fibrillation using multidedector computed tomographic angiography

Objectives: Atrial fibrilation (AF) develops from an arrhythmogenic ectopic focus, which triggers the vicious circle that creates arrhythmias. Arrhythmogenic foci are often located in the transition areas between the pulmonary veins and the left atrial endothelium. This study aims to compare the pulmonary vein anatomy of patients with and without AF using multidetector computed tomographic (MDCT) angiography and to evaluate the relationship between the presence of pulmonary vein variations and the development of AF. Methods: Seventy cases (38 males, 32 females) aged between 23 and 75 (mean age: 49.9 ± 13.3 years) were included in this study. This study consisted of 20 patients undergoing endovascular radiofrequency catheter ablation with AF and 50 participants (control) without AF. MDCT angiography examination was performed for the evaluation of pulmonary vein anatomy and variations. Results: Normal pulmonary vein anatomy was observed in 30% (n = 6) of the study group, 60% (n = 30) of the control group, and 51.4% (n = 36) of the total of both groups. Variation in pulmonary vein anatomy (accessory pulmonary vein or common ostium) was detected in 48.6% (n = 34/70) of the cases. The most common variation was the presence of accessory pulmonary vein (35.7%). Common ostium was found to be the second most common variation (12.8%). All common ostia were localized on the left side. Early branching of pulmonary veins was detected in 41 (58.5%) of 70 cases. Conclusions: Accesory pulmonary vein, common ostium and early branching are more frequently present in patients with AF.

Safety and Efficacy Using the Second-Generation Cryoballoon in Patients With Atrial Fibrillation and a Common Ostium of Inferior Pulmonary Veins.

Background: Common ostium of inferior pulmonary veins (COIPV) is a kind of pulmonary vein variation. The safety and efficacy of COIPV isolation using the second-generation cryoballoon (CB) ablation remain unknown.Methods: A total of 10 patients with COIPV from a consecutive series of 1,751 patients with atrial fibrillation (AF) were included. Pulmonary vein isolation (PVI) was performed using the second-generation CB.Results: The prevalence of a COIPV was 0.57% in this study. PVI was achieved in all pulmonary veins (PVs) without the need for a touch-up. A segmental freeze strategy was applied for each inferior PV, respectively. The mean number of freeze cycles of inferior PVs was 1.4 ± 0.5 for the left inferior pulmonary vein (LIPV), and 2.0 ± 0.9 for the right inferior pulmonary vein (RIPV). Pulmonary vein potential (PVP) of RIPV could not be monitored in real-time in three cases. Eight of 10 patients (80%) were free from atrial arrhythmias without the use of antiarrhythmic drugs during a follow-up period of 23.6 ± 12.9 months. No procedure-related complications occurred in any of the 10 patients.Conclusions: Common ostium of inferior pulmonary veins is a rare but challenging PV variant. PVI with this unusual anatomic variation using the second-generation 28-mm CB is effective and safe.

The Pulmonary Venous Return from Normal to Pathological—Clinical Correlations and Review of Literature

Pulmonary veins carry oxygenated blood from lungs to the left atrium of the heart. The anatomy of the pulmonary veins is variable with some anatomic variants. In clinical practice the difference between the normal anatomy of pulmonary veins with its variants and abnormal anatomy is very important for clinicians. Variants of pulmonary veins may occur in number, diameter and normal venous return. We present a case report and a review of the literature with the pulmonary venous return that deviates from the usual anatomical configuration and ranges from normal variant drainage to anomalous pulmonary—systemic communication. Initially, it was considered as an anatomical variant of the pulmonary venous return associated with the persistence of the left superior vena cava. Upon detailed exploration it was established that it was an anomaly of the pulmonary venous return which led in time to the installation of its complications. Diagnosis can be difficult, sometimes missed, or only made late in adulthood when complications were installed. Knowledge of variant anatomy and anomalous pulmonary venous return play a crucial role in the diagnostically challenging patient.

Morphological variations of pulmonary veins draining into left atrium: A detailed cadaveric study

Introduction: During pulmonary vein isolation ablation procedure, the knowledge of number and position of pulmonary veins with thickness of posterior wall of left atrium (LA) is of invaluable significance. The objective of the study was to determine the left atrial wall thickness (LAWT) and its relationship with number and variations of right pulmonary veins (RPVs) and left pulmonary veins (LPVs). Methodology: In an observational study, carried out in the Department of Anatomy, All India Institute of Medical Sciences, Raipur (Chhattisgarh), morphological variations of pulmonary veins among 75 formalin-fixed hearts were noted. The thickness of posterior wall of LA was measured in each specimen studied. The number of RPVs and LPVs was counted. Any sexual differences in these numbers were noted. Results: Normal anatomical description of two RPVs and two LPVs opening the LA was observed in 63 out of 75 heart specimens (84%). The posterior LAWT is ranged 1.28–1.48 mm where two RPVs and two LPVs enter LA. The remaining 12 specimens (16%) showed variation in the number of veins opening into LA ranging between 1 and 5 veins of either side. The posterior LAWT ranged between 1.01 and 2.53 mm in these 12 specimens. The mean posterior LAWT thickness with 3, 4, and 5 RPVs was 1.47, 1.94, and 2.43 mm, respectively. Conclusion: The thickness of posterior wall of LA increases as the number of RPVs increases. Twelve specimens (16%) showed variation in the number of veins opening into LA ranging between 1 and 5 veins of either side.

Uniportal VATS right superior lobectomy: management of pulmonary vein variation: a case report

BackgroundAlthough there are lots of variations of pulmonary veins including dangerous type that could cause serious complications during surgery, limited information has been reported about these variations. We have experienced an extremely rare anomaly of the right superior pulmonary vein during right superior lobectomy. We used a technique called “non fissure” to manage the right superior pulmonary vein, and the results were satisfactory.Case presentationA 66-year-old woman with lung nodules visited our hospital. Chest computed tomography revealed multiple ground glass nodules in the right lung, the main pulmonary nodule was 11 mm in diameter and presented mixed density. The patient had a previous history of rectal cancer surgery. Contrast-enhanced three-dimensional computed tomography showed that the right superior pulmonary vein abnormally ran between the pulmonary artery trunk and the right main bronchus. We performed a right superior lobectomy and lymph node sampling by uniportal video-assisted thoracoscopic surgery. The pathological findings showed microinvasive adenocarcinoma with no lymphatic metastasis. She was discharged 7 days after surgery without any surgical complications.ConclusionsAlthough the variation of pulmonary vein is uncommon, it is dangerous to misidentify in the operation. Preoperative three-dimensional computed tomography is useful for avoiding unexpected bleeding. The technique “no fissure” might be a useful way to manage the variation of pulmonary vein.

310 Computed Tomography Pulmonary Venogram Characteristics of Patients Undergoing Hybrid Atrial Fibrillation Ablation

Computed tomography pulmonary venogram can provide anatomic information of the left atrium, left atrial appendage and pulmonary veins that assist in planning radiofrequency catheter ablation for atrial fibrillation. 26 patients underwent computed tomography pulmonary venograms prior to their hybrid atrial fibrillation ablation. Left atrial abnormalities, lack of left atrial appendage opacification, pulmonary vein ostial diameters and variant anatomy were recorded. The mean pulmonary vein cross-sectional diameters were as follows:•Right superior pulmonary vein were 20.2±4.8mm x 17.8±4.3mm;•Right inferior pulmonary vein 19.6±3.9mm;•Left superior pulmonary vein 19.4±3.3mm x 16.1±2.9mm; and•Left inferior pulmonary veins 20.3±6.4mm x 16.4±3.5mm. There were 7 pulmonary vein variants. 3 patients had a common left pulmonary vein with a mean cross-sectional diameter of 33±2.6mm x 25.3±4 mm. 4 patients had right middle pulmonary veins with a mean cross-sectional diameter of 9±1.4mm x 8.5±1mm. There were no left atrial abnormalities. The left atrial appendages were well opacified. The pulmonary vein characteristics and variant anatomy were obtained. 29% of patients had variant anatomy, which is similar to the documented rates in the literature, with the most common variant being the right middle pulmonary vein.

Variations and surgical management of pulmonary vein in living-donor lobectomy.

In a living-donor lobectomy, the donor undergoes a right or left lower lobectomy. The surgical procedures for living-donor lobectomy are sometimes influenced by the anatomical variations of the pulmonary vein (PV). The goal of this study was to analyse the PV variations in living donors and to review the influence of these variations on the surgical procedures used. Between June 2008 and September 2018, 154 living donors underwent right or left lower lobectomy. The PV variations were analysed using 3-dimensional computed tomography (3D-CT), and the surgical management of these variations was reviewed. Among 154 donors, 21 PV variations that could influence the surgical procedure for a right lower lobectomy were found in 19 (12.3%) donors, whereas no such variations for a left lower lobectomy were found. Detected PV variations were dorsal branch of the right upper PV (n = 12), middle PV draining into the right lower PV (n = 6) and the superior segment branch of the right lower PV draining into the right upper PV (n = 3). Among 96 donors undergoing right lower lobectomy, 9 (9.4%) donors had PV variations that could influence the surgical procedure. In 2 donors, sparing of PV branches with multiple vascular clamps was required. Pulmonary venoplasty was not required in any donor, whereas pulmonary venoplasty in recipient surgery was required in 4 recipients. There were no complications related to the surgical procedures performed on the PV. Living-donor lobectomy was performed safely owing to the preoperative evaluation of PV on 3D-CT and the use of appropriate surgical approaches to PV.

P2.05-17 Preoperative Identification of the Left Common Pulmonary Vein for Safe Video-Assisted Lobectomy

The pulmonary veins (PVs) display many anatomical variations. Some anomalies, especially the common trunk of the left PV, are associated with serious surgical morbidity for patients undergoing lung surgery. Compared with thoracotomy, video-assisted thoracic surgery (VATS) has a limited view of the surgical field, thus thoracic surgeons must be familiar with anatomical variations in the PVs. We aimed to investigate the anatomical variants of the left PVs using three dimensional (3D)- computed tomography (CT) images. We reviewed anatomical variations of the left PVs of 156 consecutive patients who had undergone surgical pulmonary resection at our institution, using the multidetector contrast-enhanced CT. The common trunk was defined anatomically as the presence of a single ostium at the point of reflection of the parietal pericardium along the left atrium. We identified the common trunk of the left PV in 11 of the 156 patients (7.1%), and the discrete left lingular vein (V4+5) draining near the inferior PV in 2 patients (1.2%). Of which, 5 had the long common trunk; the length of the common trunk outside the pericardium was equal to or longer than 10mm. Of these 11 patients, 5 were men, 4 had hypertension, 3 had valvular disease, 1 had coronary artery disease, 1 had paroxysmal atrial fibrillation (Paf), and the remaining 7 had no hypertension or structural heart disease. Although the anatomical variants of PV have been related to a higher arrhythmogenic potential, only 1 (9%) patient had postoperative complication of Paf. In 11 cases, 3 had incomplete lobulation and 3 had left lingular pulmonary artery arising from pars mediastinalis. The common trunk of the left PV was accompanied by other variant anatomies, that included; 1) right V6 draining into the superior PV in 3 cases; 2) right superior vein passing dorsal to right main pulmonary artery in 1 case; 3) supernumerary bronchus corresponding to left B7 in 2 cases. We encountered three cases demonstrating a common trunk of the left PV during VATS lobectomy. 3D-CT reconstruction was useful for recognizing such anomalies before surgery and allows safe VATS lobectomy. In surgical findings, the common trunk was located in the normal superior pulmonary vein drained into the left atrium. We should expose this vein adequately and dissect peripherally for confirmation of the common trunk. We conclude that the common trunk of the left PV is not a very rare anomaly and might be accompanied by other variant anatomies. Careful preoperative radiological evaluation of the pulmonary veins is essential to perform safe VATS lobectomy. 3D-CT can provide detailed information for assessing abnormalities of venous return.

Procedural findings and clinical outcome of second-generation cryoballoon ablation in patients with variant pulmonary vein anatomy.

The procedural findings and clinical outcome of second-generation cryoballoon (CB2) ablation in patients with variant pulmonary vein (PV) anatomy have not been fully investigated. A total of 424 consecutive patients who underwent PV isolation with CB2 were included. Computed tomographic (CT) scan was performed in all patients before the procedure. The study population was divided into common PV, accessory PV, and nonvariant PV groups according to the CT scan. Procedural findings and clinical outcome between the three groups were compared. Variant PV anatomy was observed in 118 of 424 (27.8%) patients. PV isolation was successfully achieved in all patients in three groups with low rates of need for touch-up ablation (P = 0.974). Total procedure time was longer in the accessory PV group compared with nonvariant PV group (53.7 ± 12.9 vs 49.5 ± 8.8 minutes; P < 0.001). More number of applications per patient were required in accessory PV group compared with the nonvariant PV and common PV groups (7.5 ± 2.1 vs 6.5 ± 1.6, P < 0.001; 7.5 ± 2.1 vs 6.8 ± 1.4, P = 0.027, respectively). No significant difference in phrenic nerve (PN) injury was observed between the three groups (P = 0.693). During mean follow-up duration of 16.1 ± 3.3 months, there was no significant difference in rates of atrial fibrillation (AF) recurrences in the three groups (13 of 43 common PV group, 21 of 75 accessory PV group, and 80 of 306 nonvariant PV group, P = 0.178). Variant PV patterns are common in patients undergoing ablation for drug-resistant AF. CB2 ablation appears to be a reasonable strategy in the setting of the variant PV anatomy with a small increase in procedure time and the number of cryoapplications.

A study on pulmonary venous ostia pattern in the left atrium and its clinical applications

Abstract Background &amp; aims : Normally four pulmonary veins open into the left atrium. Frequently there are variations in the number of pulmonary veins opening in to the left atrium. Ectopic beats in atrial fibrillation commonly originates from the ostia of the pulmonary veins. The treatment of atrial fibrillation is by radio frequency ablation of the focus of origin and hence the knowledge of anatomical variation of pulmonary veins is necessary to find the ectopic focus in the origin of atrial fibrillation. Materials and Method : In this study the variation of pulmonary venous ostia pattern in the left atrium was studied in 80 formalin fixed adult cadaveric hearts. Results and Conclusion : 63 hearts showed no variation in the pulmonary venous ostia pattem which accounts for 78.75%, rest of the 17 hearts showed variation in the pulmonary venous ostia which accounts for 21.25%, the variation in the number of pulmonary veins was slightly higher for the left side [11.25%] when compared to the right sided variation [ 10%], the number of hearts which showed bilateral variation was noted in 2 hearts - both showed a single pulmonary vein opening on either side which accounts for 2.5%

Impact of Pulmonary Vein Anatomy on Long-term Outcome of Cryoballoon Ablation for Atrial Fibrillation

Variant pulmonary vein anatomy (PVA) has been reported to influence the recurrence of atrial fibrillation (AF) after radiofrequency ablation. However, the effects of PVA on AF in patients undergoing cryoballoon ablation (CBA) remain unknown. The present study aimed to examine the impact of PVA on the long-term outcome of CBA for AF. A total of 78 patients (mean age 60.7±10.9 years, 64.1% males) with symptomatic and drug-refractory paroxysmal AF were enrolled in the study. Left atrium (LA) and PVA acquired at computed tomography angiography (CTA) were reconstructed with CARTO® 3 SYSTEM. Patients were routinely evaluated by 24-hour Holter monitoring following CBA. Cox regression was used to detect the predictors of AF recurrence after CBA. The results showed abnormal PVA in 30 patients (38.5%) and 18 patients (23.1%) had left common PV (LCPV). Electrical pulmonary vein isolation was achieved in all patients. After a mean follow-up of 689.5±103.8 days, it was found that patients with abnormal PVA had similar AF recurrence rate to those with normal PVA (26.7% vs. 25.0%, P=0.54), and there was no significant difference in AF recurrence rate between LCPV patients and non-LCPV patients (33.7% vs. 23.3%, P=0.29). Cox regression analysis showed that AF duration (72.9±9.0 vs. 42.3±43.2 months, HR 1.001; 95%CI 1.003-1.014; P<0.001) and cryo-applications of right-side PVs (3.0±1.6 vs. 4.7±1.7, HR 0.661; 95% CI 0.473-0.925; P=0.016) were independent predictors of freedom from AF, but PVA was not identified as a predictor of long-term success. In conclusion, the variant PVA cannot significantly influence the long-term outcome of AF patients undergoing CBA; longer AF duration and less cryo-applications of right-side PVs are associated with higher AF recurrent rate.

Evaluation of pulmonary vein anatomy using 256-slice computed tomography

Background/aim: This study aimed to evaluate pulmonary vein (PV) anatomy using 256-slice computed tomography (CT), which may be necessary for electrophysiologists to know before radiofrequency catheter ablation (RFCA) therapy.Materials and methods: A total of 102 patients with paroxysmal and persistent atrial fibrillation underwent 256-slice cardiac CT angiography prior to catheter ablation. PV morphology, ostial diameter, ostial orientation, and distance from ostium to first bifurcation were evaluated using three-dimensional volume-rendering and multiplanar-reformatting technology. Results: We found that 72.5% of patients had four conventional PVs. On the right, 22.5% of patients had one accessory PV, 4.9% had 2 accessory PVs, 1% had one common PV, and 1% had one top vein. On the left, 27.5% of patients had one common PV. Additionally, 9.8% of patients had bilateral PV variation. Ostial size was larger for superior PVs than inferior PVs and larger for right PVs than left PVs. PV ostia on the right tended to be more circular. There was a rather wide variation of projective angle and distance from ostium to first bifurcation. Early branching occurred more often in the right inferior PV. Conclusion: 256-Slice CT can depict PV anatomy and afford substantial data, which will help electrophysiologists conduct the RFCA procedure safely and efficiently.