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Review
. 2010 Jun 1;3(1):265.
doi: 10.4022/jafib.265. eCollection 2010 Jun-Jul.

Is Isolation of Arrhythmogenic Pulmonary Veins Sufficient for the Long-term Efficacy of Atrial Fibrillation Ablation?

Sanjay Dixit  1
Affiliations
Review

Is Isolation of Arrhythmogenic Pulmonary Veins Sufficient for the Long-term Efficacy of Atrial Fibrillation Ablation?

Sanjay Dixit. J Atr Fibrillation. .
No abstract available

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Figures

Figure 1.
Figure 1.. Panel A shows pulmonary vein depolarization (PVD; green arrows) recorded on the distal pole of ablation catheter (Abl ds) positioned in the left inferior (LI) PV with constant exit time out of the vein (interrupted line to generate atrial premature complexes (APCs). Panel B shows PVD response to isoproterenol infusion which causes increased frequency and the first PVD demonstrates shorter exit time compared with the second more closely coupled PVD that takes longer to exit out of the vein. Such behavior is consistent with facilitated and decremental conduction. From top to bottom the tracings are arranged as follows: ECG lead V1, Lasso (Ls; poles 9,10 to 1,2) positioned in the right superior PV, proximal (px) and distal (ds) poles of ablation catheter positioned in LIPV, decapolar catheter positioned in the posterior right atrium (CR5 – CR1) and decapoler catheter positioned in the coronary sinus (CS1,2 – CS 9,10)
Figure 2.
Figure 2.. From top to bottom are ECG lead V1, 10 bipolar recordings of circular mapping (Lasso) catheter located at LIPV Os, recordings from distal and proximal bipoles of ablation catheter located in LSPV and 5 bipolar recordings from catheters positioned in coronary sinus (CS) and right atrium (RA). Initial two beats represent sinus rhythm with delayed conduction within LIPV (arrow heads). The 3rd beat is an atrial premature complex (APC) which degenerates into AF. Note earliest electrical depolarization in the distal bipole of the ablation catheter (star) preceding APC. Similar electrical activity is noticed in the distal bipole of the ablation catheter after the 1st sinus beat (open arrow). This may represent localized “depolarization” within the LSPV that fails to propagate within or exit the vein
Figure 3A.
Figure 3A.. Panel A: Illustrates the commonest pattern of sustained pulmonic vein firing (PVF) observed in our study. From top to bottom, the arrangement of tracings are: surface lead V1 , recordings from decapolar circular mapping catheter (Lasso) positioned at os of left superior pulmonic vein, distal bipole of ablation catheter positioned just beyond os of right superior pulmonary vein (RSPV), and recordings (distal to proximal) from decapolar catheters along the posterior right atrium (Ct) and in the coronary sinus (CS) respectively. Discrete multiphasic electrograms (Egm) representing spontaneous PVF are seen on the bipole of ablation catheter (arrow heads) that do not correspond in timing with P, QRS, or T waves. Since PVF occurs after each sinus beat, we define this pattern as bigeminal. Please note that PVF in this case does not exit out of the RSPV
Figure 3B.
Figure 3B.. Panel B : Illustrates another pattern of sustained pulmonic vein firing (PVF). The arrangement of tracings are identical to Panel A. Discrete multiphasic electrograms (Egm) representing spontaneous PVF are seen on the bipole of ablation catheter (arrow heads) and do not correspond in timing with P, QRS, or T waves. In this case, PVF occurs after every two sinus beat, and so the pattern is trigeminal. It can be appreciated from the figure that the 1st and last PVF exit out of the vein, generating atrial premature complexes (APCs) with expected alteration of intracardiac activation patterns and surface P wave morphology
Figure 4A.
Figure 4A.. Panel A: Illustrates response of sustained pulmonic vein firing (PVF) to overdrive pacing. The arrangement of tracings are similar to figure 1 and decapolar circular mapping catheter (Lasso) is positioned at os of right superior pulmonic vein (RSPV). Following both the initial sinus beats, discrete multiphasic electrograms (Egm) representing spontaneous pulmonic vein PVF (open boxes) are seen on multiple bipoles of Lasso catheter and result in atrial premature complexes. Pacing is initiated from distal most bipole of CS catheter(interrupted line) and capture of both atria is achieved with the second pacing drive (arrow head). Almost immediately with capture of overdrive pacing no further PVF is seen for the rest of the recording. Such early PVF suppression (within 5 seconds) in response to overdrive pacing was observed in the majority of cases in our study
Figure 4B.
Figure 4B.. Panel B: Is the continuation of the example in Figure 1, Panel A (with identical arrangement of tracings) and represents termination of the 60-second pacing drive from the distal CS bipole (cycle length 600 msec). Recurrence of PVF post pacing (open box) is seen after the 2nd sinus beat and occurs within 5 seconds of pacing drive termination (early recurrence). This pattern of early PVF recurrence post pacing was a commonly observed response in our study
Figure 5A.
Figure 5A.. Panel A: IIllustrates sustained pulmonic vein firing (PVF) at baseline seen as discrete multiphasic electrograms (Egm) on multiple poles of Lasso catheter (open boxes) positioned at os of left inferior pulmonary vein (LIPV). The arrangement of tracings areas in previous figures. PVF in this case does not exit out of the LIPV
Figure 5B.
Figure 5B.. Panel B: This figure represents pulmonic vein firing (PVF) in the same patient as in Panel A. In response to isoproterenol, there is increase in the heart rate. Also evident is an increase in the frequency of PVF (multiple discrete electrograms on several bipoles of Lasso catheter – open boxes) with and without conduction out of the vein resulting in atrial premature complexes. This constitutes augmentation of sustained PVF in response to isoproterenol
Figure 6.
Figure 6.. This figure represents pulmonic vein firing (PVF) in the same patient as in Panel A. In response to isoproterenol, there is increase in the heart rate. Also evident is an increase in the frequency of PVF (multiple discrete electrograms on several bipoles of Lasso catheter – open boxes) with and without conduction out of the vein resulting in atrial premature complexes. This constitutes augmentation of sustained PVF in response to isoproterenol
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