Atrial mapping during pulmonary vein pacing: a novel maneuver to detect and close residual conduction gaps in an ablation line

Abstract

BackgroundLocation of residual conduction gaps on ablation lines around pulmonary veins (PV) is challenging, and several maneuvers have been described. Atrial mapping during PV pacing—the “pace and map” maneuver—could localize gaps.Methods and resultsWe prospectively studied 209 patients undergoing PV isolation at a single institution over a 25-month period. In 24 (11.4 %) patients, 26 PV remained connected after an ablation line and an initial conventional gap closure protocol. The atrial side of the ablation line was mapped with the ablation catheter during PV pacing, and the earliest site was considered a gap site. Ablation at these gap sites resulted in bidirectional PV conduction block in 22 PV (85 %) in 21 patients (88 %), after 2.2 ± 1.6 radiofrequency applications and 8.2 ± 4.8 min. Early PV reconnection (≥20 min) occurred in 0 PV (0 %). During a mean follow-up of 12 ± 6 months, eight patients (33 %) had arrhythmia recurrences.ConclusionsThe “pace and map” maneuver is a relatively simple and efficacious means to identify gaps in ablation lines around PV, focusing on the atrial rather than the PV side of the line. It could be considered among the ways to eliminate residual conduction gaps.

Localization of Residual Conduction Gaps After Wide Antral Circumferential Ablation of Pulmonary Veins

“…Indeed, in the study by Bacquelin et al,[33] only two thirds of the connections were located in the region of the earliest-activated dipole of the CMC. In the recent study by Salas et al, [34] a concordance between gap location and the earliest PV EGM in the CMC during pacing was only found in 25% of the cases, with an average distance between the gap to the site in front of the earliest PV EGM of 20.4±9.6 mm. The anatomy of muscle sleeves may explain such discrepancies since they are often composed of circular or spirally oriented bundles of myocytes with additional longitudinally or obliquely oriented ones, forming a mesh-like structure.…”

“…Briefly, the atrial side of the ablation line is mapped with the ablation catheter during PV pacing (Figure 1, panel D). [34] Bipolar pacing is conducted at 600 ms, 10 mA / 2 ms from the CMC placed inside the PV. A pacing bipole located clearly inside the PV (as shown by the 3D mapping system) is chosen, if a consistent capture is obtained.…”

How to map and ablate a pulmonary vein–to–right atrium breakthrough during simultaneous persistent pulmonary vein fibrillation and organized atrial fibrillation using an automated high-resolution mapping system

“…Several strategies have been proposed for mapping conduction gaps between the PVs and atrium along the PV isolation lines. 9 , 10 , 11 , 12 , 13 The previous mapping maneuvers using 3-dimensional electroanatomic systems can be performed during sinus or a paced rhythm. PV-to-atrium breakthroughs usually cannot be mapped if disorganized atrial electrograms are continuously recorded during persistent AF, whereas atrium-to-PV breakthroughs also cannot be mapped if disorganized PV electrograms are continuously recorded during persistent PV fibrillation.…”

Escape mapping to achieve bidirectional block: A case series

“…as a method to identify conduction gaps during an AF ablation. This method requires two catheters in the LA, as conduction gaps are identified by pacing within the PVs while simultaneously mapping on the atrial side of the ablation line with a second catheter . Performing AF ablations with a single catheter in the LA is a well‐established, safe, effective, and cost‐saving alternative to a traditional two‐catheter approach .…”

“…This method requires two catheters in the LA, as conduction gaps are identified by pacing within the PVs while simultaneously mapping on the atrial side of the ablation line with a second catheter. 4 Performing AF ablations with a single catheter in the LA is a wellestablished, safe, effective, and cost-saving alternative to a traditional two-catheter approach. 5 However, a single catheter approach can Escape mapping is a useful strategy as it can be performed with only a single catheter in the atrium and a CS catheter for reference.…”