Bigeminal Pulmonary Vein Ectopy Suppressed by Pulmonary Vein Isolation

Abstract

SUMMARYA 58-year-old man with atrial fibrillation underwent pulmonary vein (PV) isolation (PVI). Bigeminal atrial premature beats persisted from the beginning of the PVI. The cardiac recordings from a basket catheter (BC) revealed the PV ectopic origin in the distal right superior PV. Successful PVI with the guidance of BC was confirmed by the appearance of concealed ectopy. Surprisingly, the PV ectopy completely disappeared immediately after the successful PVI. The findings suggest that the generation of PV trigger is sometimes dependent on left atrial input and that the underlying mechanism of the PV trigger may have been triggered activity or reentry. (Int Heart J 2008; 49: 129-132) Key words: Premature atrial contraction, Bigeminy, Pulmonary vein, Isolation THE pulmonary veins (PVs) have been demonstrated to be the major source of ectopic beats triggering paroxysmal atrial fibrillation (AF) and the electrical activity generating the ectopic beats can be recorded from the PV sleeve. 1-3)Although previous studies of PV electrophysiology have proposed that triggered activity or reentry favored by left atrial inputs may cause PV tachycardia during AF, 4-6) the details of the mechanism of PV ectopic beats triggering AF are still unknown. CASE REPORTA 58-year-old Japanese man with idiopathic, drug-refractory paroxysmal AF was referred for an electrophysiologic study (EPS) and radiofrequency catheter ablation. He complained of palpitations from AF which continued for a few hours, 2 or 3 times a week despite taking antiarrhythmic drugs. There was no echocardiographic evidence of structural heart disease. The left atrial dimension From the

Intrinsic Cardiac Autonomic Stimulation Induces Pulmonary Vein Ectopy and Triggers Atrial Fibrillation in Humans

“…In this case, the source of earliest recorded ectopy was eventually localized to the left lower PV adjacent to the site of stimulation by sequentially moving the PV catheter from the right upper PV, to the left upper PV, and finally to the left lower PV, while maintaining stimulation at the GP site adjacent to the left lower PV. Together with our finding that over 76% (48 of 63) of the earliest recorded ectopic responses originated from the PV directly adjacent to the site of stimulation, these observations support the notion that the GP serves as the left atrial inputs 18,19 that influence PV electrophysiology.…”

“…showed that intermittent bursts of PV tachycardia are observed during AF, but these PV tachycardias almost always resolve with PV isolation, suggesting a dynamic interplay between the atria and PVs, with intermittent bursts of PV tachycardia being dependent on left atrial input. A recent case report demonstrating concealed PV ectopy from the distal right upper PV that abruptly ceases on isolation of the same PV supports the idea that PV firing may be dependent on left atrial inputs 19 …”

Bigeminal potentials in the pulmonary vein indicate arrhythmogenic trigger of atrial fibrillation

“…Bigeminal PV potentials (PV bigeminy) are rare phenomenon characterized by a second series of PV potential that is separate in time phase from the ordinary PV potentials observed in the PV ostia during sinus rhythm. Pathophysiology and clinical implications of PV bigeminy still remain unclear 6–11 . A recent study has suggested that a concealed PV bigeminy may be an indicator of arrhythmogenic activity 11 .…”

A pseudo-sinus rhythm due to bigeminal ectopy with the focus in the right superior pulmonary vein

“…It has been reported that pulmonary vein ectopy is a common origin of focal atrial tachycardia 1 ; however, only a few cases of pulmonary vein rhythm treated by pulmonary vein isolation (PVI) have been reported. 2 , 3 We present the rare case of a patient who presented with a “pseudo-sinus rhythm” even though he had undergone PVI and was ultimately found to have bigeminal ectopy from the reconnected right superior pulmonary vein (RSPV).…”