Acute and Chronic Pulmonary Vein Reconnection after Atrial Fibrillation Ablation: A Prospective Characterization of Anatomical Sites

Rajappan, Kim; Kistler, Peter M.; Earley, Mark J.; Thomas, Glyn; Izquierdo, Maite; Sporton, Simon; Schilling, Richard J.

doi:10.1111/j.1540-8159.2008.01232.x

Cited by 117 publications

(86 citation statements)

References 28 publications

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“…It is interesting to acknowledge that in a study evaluating acute and chronic PV reconnection after AF ablation, Rajappan et al 29 identified that besides the intervenous ridge (between ipsilateral PVs), the preferential site of acute reconnection is the PV-LAA ridge, and the preferential sites of chronic reconnections were at the PV-LAA ridge, the roof of the right superior PV, and the floor of the right inferior PV. Even though atrial arteries were not commonly found in our work at the inferior segment of the right inferior PV, atrial arteries were prevalent at the other areas described as sites of frequent reconnection.…”

Section: Discussionmentioning

confidence: 99%

Atrial Coronary Arteries in Areas Involved in Atrial Fibrillation Catheter Ablation

Meo

Scanavacca

Sosa

et al. 2010

Circ: Arrhythmia and Electrophysiology

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Background-The proximity to vascular structures is a limiting factor during radiofrequency ablation. However, little or no attention has been given to the atrial arterial circulation during the development of atrial fibrillation (AF) catheter ablation techniques. Methods and Results-We examined the atrial arterial circulation in areas involved in AF ablation in 24 heart specimens by colored resin injection and careful dissection. The sinus node artery (SNA) arose from the circumflex artery in 42% of case; proximal to the LA appendage in 29%, crossing the left atrium (LA) anterior wall; and after the LA appendage in the remaining 13%, crossing the mitral isthmus and passing close to the left pulmonary veins (PVs), the LA roof, and the right superior PV. In 58%, the SNA arose from the right coronary artery. Major arteries (Ն1 mm in external diameter) were found in the mitral isthmus in 54%, at the LA roof in 54%, and at the LA anterior wall in 29%. Around the left PV ostia, there were areas with major arteries in up to 37% (at the roof and inferior segments) and around the right PV ostia in up to 29% (at the roof segment). Conclusions-Major atrial coronary arteries, including the SNA, were commonly found in the areas involved in AF ablation and could cause difficulties in obtaining transmural lesions and electric isolation or even lead to ischemic sinus node or atrial dysfunction. (Circ Arrhythm Electrophysiol. 2010;3:600-605.)Key Words: arteries Ⅲ atrium Ⅲ catheter ablation Ⅲ anatomy Ⅲ atrial fibrillation A trial fibrillation (AF) is the most common arrhythmia in clinical practice, with an estimated prevalence of 0.4% to 1% in the general population 1,2 and rising with age to 8% in patients Ͼ80 years. 3 Its pharmacological treatment has yielded suboptimal results, leading to a search for nonpharmacological options for therapy. 4 Clinical Perspective on p 605During the development of the surgical approaches for AF ablation, knowledge of the atrial coronary artery anatomy was essential, leading to important technical modifications and better results. Recognition of the importance of the sinus node artery (SNA) and its relationship to the areas of atrial surgical incisions contributed to refinement in surgical technique with the maze III procedure, 5 reducing sinus node and atrial dysfunction commonly found after the initial maze I surgery. Later studies with the atrial coronary anatomy in dogs led to the proposal of the radial incisions technique, 6 reducing even further the mechanic dysfunction observed during the follow-up of patients submitted to the initial techniques. 7 The earliest techniques of radiofrequency (RF) catheter ablation simulated the surgical maze procedure 8 or attempted to eliminate ectopic foci inside the pulmonary veins (PVs). 9 In more recent modifications, endocardial RF pulses are delivered circumferentially around the PV antrum to obtain electric isolation 10,11 associated with linear ablations in the left atrium (LA) and mitral isthmus in selected patients. 12 Despite the atrial coronar...

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Section: Discussionmentioning

confidence: 99%

Atrial Coronary Arteries in Areas Involved in Atrial Fibrillation Catheter Ablation

Meo

Scanavacca

Sosa

et al. 2010

Circ: Arrhythmia and Electrophysiology

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“…6 Histopathology has shown variable atrial thickness around the PV ostia. In particular, important atrial muscle thickness has been observed at the ridge between the LSPV and left atrial append- Looking at the location of PV reconnections, and taking into account the impact of cryoballoon size on PV reconnection distribution, it is likely that the mechanisms leading to conduction recovery differ according to PVs: difficulty in correct positioning of the cryoballoon seems to be the predominant cause of PV reconduction at the RIPV; and geometrical mismatch between the cryoballoon and the PV ostium is likely involved in LIPV reconduction; Technological refinements of both the deflectable sheath and the cryoballoon catheter may improve energy delivery and the maintenance of PVI over time.…”

Section: Discussionmentioning

confidence: 99%

Lessons From Radiofrequency Redo-Procedure After Cryoballoon Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation

Godin

Savouré

Gardey

et al. 2013

Circ J

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“…period of 30 to 60 minutes. 21,22 Additional RF lesions to ensure isolation of PVs showing acutely recovered conduction provides similar long-term AF control to that seen in patients without early reconnection 23 and better AF control than in cases in which early reconnection was not explored. 24 Based on these observations, some authors recommend a 60-minute waiting period after initial PVI to detect early recurrences of conduction.…”

Section: Clinical Significance Of Pv Reconnectionmentioning

confidence: 99%

Mechanisms by Which Adenosine Restores Conduction in Dormant Canine Pulmonary Veins

et al. 2010

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Background-Adenosine acutely reconnects pulmonary veins (PVs) after radiofrequency application, revealing "dormant conduction" and identifying PVs at risk of reconnection, but the underlying mechanisms are unknown. Methods and Results-Canine PV and left-atrial (LA) action potentials were recorded with standard microelectrodes and ionic currents with whole-cell patch clamp before and after adenosine perfusion. PVs were isolated with radiofrequency current application in coronary-perfused LA-PV preparations. Adenosine abbreviated action potential duration similarly in PV and LA but significantly hyperpolarized resting potential (by 3.9Ϯ0.5%; PϽ0.05) and increased dV/dt max (by 34Ϯ10%) only in PV. Increased dV/dt max was not due to direct effects on I Na , which was reduced similarly by adenosine in LA and PV but correlated with resting-potential hyperpolarization (rϭ0.80). Adenosine induced larger inward rectifier K ϩ current (I KAdo ) in PV (eg, -2.28Ϯ0.04 pA/pF; -100 mV) versus LA (-1.28Ϯ0.16 pA/pF). Radiofrequency ablation isolated PVs by depolarizing resting potential to voltages positive to -60 mV. Adenosine restored conduction in 5 dormant PVs, which had significantly more negative resting potentials (-57Ϯ6 mV) versus nondormant (-46Ϯ5 mV, nϭ6; PϽ0.001) before adenosine. Adenosine hyperpolarized both, but more negative resting-potential values after adenosine in dormant PVs (-66Ϯ6 mV versus -56Ϯ6 mV in nondormant; PϽ0.001) were sufficient to restore excitability. Adenosine effects on resting potential and conduction reversed on washout. Spontaneous recovery of conduction occurring in dormant PVs after 30 to 60 minutes was predicted by the adenosine response. Key Words: arrhythmia ablation Ⅲ adenosine Ⅲ atrium Ⅲ conduction Ⅲ electrophysiology Ⅲ ion channels P ulmonary vein isolation (PVI) is an effective treatment for atrial fibrillation (AF). 1,2 Nevertheless, many patients require repeated ablation procedures because of AF recurrence, which in most cases are associated with reconnection of previously isolated PVs. 3,4 It has recently been noted that intravenous purinergic agonists such as adenosine can transiently restore conduction through a previously isolated PV, a phenomenon called "dormant conduction." [5][6][7][8] The demonstration of dormant conduction has predictive value for eventual reconnection, and additional radiofrequency (RF) applications to veins showing dormant conduction at the time of initial PVI may prevent reconnection and AF recurrence. 6 -8 The mechanisms by which adenosine restores conduction to dormant PVs are unknown. The objectives of this study were to (1) explore the effects of adenosine on ionic currents and action potentials (APs) in canine left-atrial (LA) and PV cardiomyocytes, and (2) relate these effects to changes in conduction between the PV and LA after RF ablation in an in vitro model. Conclusions-Adenosine Clinical Perspective on p 972 Materials and MethodsSee the online-only Data Supplement for the complete Materials and Methods section. The following text summarize...

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Acute and Chronic Pulmonary Vein Reconnection after Atrial Fibrillation Ablation: A Prospective Characterization of Anatomical Sites

Cited by 117 publications

References 28 publications

Atrial Coronary Arteries in Areas Involved in Atrial Fibrillation Catheter Ablation

Atrial Coronary Arteries in Areas Involved in Atrial Fibrillation Catheter Ablation

Lessons From Radiofrequency Redo-Procedure After Cryoballoon Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation

Mechanisms by Which Adenosine Restores Conduction in Dormant Canine Pulmonary Veins

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