Characteristics of right pulmonary vein with an epicardial connection needing additional carina ablation for isolation

Abstract

BackgroundThis study thought to elucidate the anatomical features that can predict an epicardial connection (EC) between the right pulmonary vein (RPV) and right atrium.MethodsWe retrospectively analyzed 251 consecutive patients undergoing initial radiofrequency pulmonary vein isolation. We defined EC as present when RPV could not be isolated with circumferential ablation and additional ablation for the conduction gap if needed, and RPV isolation could be achieved by ablation for the earliest activation site >10 mm inside the initial ablation line. Using computed tomography data, we evaluated the RPV bifurcation angle, and the area occupation ratio of the carina region to the RPV antrum (ARC) for predicting EC. In subjects with EC undergoing RPV activation mapping after circumferential ablation, the correlation between conduction delay and bipolar/unipolar potential voltage in the carina region was investigated.ResultsThere were ECs in 45 out of 251 patients (17.9%). The RPV bifurcation angle (47.7° vs. 38.8°, p < .001) and ARC (37.2% vs. 29.7%, p < .001) were significantly greater in the EC (+) group. Multivariate logistic regression analysis revealed that RPV bifurcation angle (odds ratio [OR]: 1.994, p = .002) and ARC (OR: 3.490, p = .013) were independent predictors of EC. In nine patients with EC undergoing carina region mapping, the unipolar potential voltage was correlated with conduction delay in RPV with EC (R = −0.401, p < .001).ConclusionAnatomical features suggesting a wider RPV carina region could predict the presence of EC, and potential with high voltage could be helpful for detecting EC connection sites.

How to predict the existence of epicardial conduction in the right pulmonary vein carina

“…In their study, the authors mentioned that observing high‐voltage PV potential in the RPV carina subsequent to RPV circumferential ablation aided in suspecting the presence of epicardial conduction. 1 Nevertheless, this observation might not deviate significantly from the conventional procedure, which entails re‐mapping to ascertain the site of earliest activation following RPV circumferential ablation. Instead, an alternative concurrent procedure alongside conventional RPV circumferential ablation ought to be proposed in instances where the RPV carina exhibits high voltage.…”

“…The authors postulated that epicardial conduction toward the RPV carina originated from the right atrium. 1 Nonetheless, they did not provide demonstrative evidence of a connection between the right atrium and the RPV carina. 2 Was right atrial mapping performed by the authors to substantiate their hypothesis?…”

“…The authors presented evidence indicating that anatomical features suggestive of a wider RPV carina region were predictive of the existence of an epicardial connection. 1 However, several concerns have emerged from their study.…”

“…Although the authors hypothesized the existence of epicardial conduction, 1 it is plausible that alternative conduction pathways toward the RPV carina exist. Notably, a lower contact force has been associated with RPV carina breakthrough after PV ablation.…”

“…The authors explored the implication of anatomical features in patients undergoing circumferential ablation. 1 PV isolation can be achieved using alternative modalities such as cryoballoon ablation, and RPV carina may also be concurrently ablated using these balloon‐based procedures. The concerns regarding the issue of epicardial connections at the RPV carina may not be problematic in such a procedure.…”