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. 2021 Dec 27;38(1):97-105.
doi: 10.1002/joa3.12672. eCollection 2022 Feb.

Incidence of epicardial connections between the right pulmonary vein carina and right atrium during catheter ablation of atrial fibrillation: A comparison between the conventional method and unipolar signal modification

Hiroki Yano  1 , Taku Nishida  1 , Junichi Sugiura  1 , Ayaka Keshi  1 , Koshiro Kanaoka  1 , Satoshi Terasaki  1 , Yukihiro Hashimoto  1 , Yasuki Nakada  1 , Hitoshi Nakagawa  1 , Tomoya Ueda  1 , Ayako Seno  1 , Kenji Onoue  1 , Makoto Watanabe  1 , Yoshihiko Saito  1
Affiliations

Incidence of epicardial connections between the right pulmonary vein carina and right atrium during catheter ablation of atrial fibrillation: A comparison between the conventional method and unipolar signal modification

Hiroki Yano et al. J Arrhythm. .

Abstract

Background: When performing an electrical isolation of ipsilateral pulmonary veins (PVs) for atrial fibrillation, physicians often need additional radiofrequency (RF) ablation in the carina region between the superior and inferior PVs to achieve a right PV isolation because of intercaval bundles between the right PVs and right atrium (RA). We compared the efficacy of a high-power and short-duration ablation guided by unipolar signal modification (UM) with the conventional method (CM) for ablating epicardial connections between the right PV carina and RA.

Methods: The study subjects consisted of patients who underwent an initial box isolation of atrial fibrillation from January 2015 to December 2019 at Nara Medical University Hospital. Among these patients, 94 and 65 patients who met the criteria were assigned to the CM and UM groups, respectively. We retrospectively analyzed the anterior ablation line of the right PV using an electroanatomical mapping system. Patients whose initial ablation line included the right PV carina were excluded.

Results: Six and seven patients were, respectively, excluded from the CM and UM groups. Among 88 CM group patients, 21 needed additional right PV carina ablation, while among 58 UM group patients, 30 needed additional right PV carina ablation (p = .001). No anatomical factors were associated with the additional right PV carina ablation.

Conclusions: Compared to the CM group, a box isolation was less achievable without RF ablation at the right PV carina in the UM group. We should consider a long-duration ablation for epicardial connections between the right PV carina and RA.

Keywords: atrial fibrillation; carina; epicardial connection; high‐power; unipolar signal modification.

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Conflict of interest statement

Authors declare no conflict of interests for this article.

Figures

FIGURE 1
FIGURE 1
Ablation sites on a 3D CARTO map of the LA. A patient without an additional right PV carina ablation (Top) and a patient with an additional right PV carina ablation (Bottom) are shown. In the patient at the bottom, the pulmonary veins and LA were electrically isolated with an right PV carina ablation inside the first right PV ablation line. 3D, three dimensional; LA, left atrium; PV, pulmonary vein
FIGURE 2
FIGURE 2
Unipolar atrial EGMs recorded before and after the ablation of the right PV anterior line in a case who required additional right PV carina ablation. This figure shows the intracardiac EGMs before (left panel) and after (right panel) the RF application. Surface ECG lead aVF, bipolar EGMs (Abl 1‐2 and Abl 3‐4), and unipolar EGMs (Abl 1) recorded by the ablation catheter are shown. The unipolar signal changed from a positive–negative morphology to a positive morphology (orange circle). ECG, electrocardiogram; EGMs, electrograms; PV, pulmonary vein; RF, radiofrequency
FIGURE 3
FIGURE 3
Gross anatomy of the epicardial connections between the right PV and RA. This dissection of the posterior and inferior parts of the interatrial groove shows multiple muscle bridges (arrows) connecting the LA and RA. ICV, inferior caval vein; LA, left atrium; LI, left inferior pulmonary veins; LS, left superior pulmonary veins; PV, pulmonary vein; RA, right atrium; RI, right inferior pulmonary veins; RS, right superior pulmonary veins; SCV, superior caval vein. Adapted from Ho et al
FIGURE 4
FIGURE 4
Ablation sites and local potentials on a 3D CARTO map of the LA. The ablation sites in the patient with an additional right PV carina ablation and successful site (green arrow) are shown. The local potentials at the success site (Abl Bipolar 1–2) were earlier than those near the right PV anterior line (Abl Bipolar 3–4). This is the same case as in Figure 2. 3D, three dimensional; LA, left atrium; PV, pulmonary vein; RA, right atrium
See this image and copyright information in PMC

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