Importance of the relative epicardial connection locations and right‐sided pulmonary vein isolation line for successful pulmonary vein isolation

Abstract

Introduction The presence of an epicardial connection (EC) decreases the success rate of pulmonary vein isolation (PVI); however, the effect of designing isolation lines has not been evaluated. We sought to clarify the effects of designing an anterior line for right‐sided PVI considering the presence and location of the EC. Methods Seventy‐four consecutive patients who underwent initial catheter ablation for atrial fibrillation were retrospectively included in this study. The presence of the EC was determined by the left atrial (LA) activation map during right atrial pacing, and patients were divided into EC‐positive (n = 23, 31%) and EC‐negative (n = 51, 69%) groups. EC‐positive patients were further subdivided based on the EC location: on‐the‐line group, (EC on the PVI line, n = 11); inside‐line group (EC on the pulmonary vein [PV] side, n = 10); and outside‐line group (EC on the LA side, n = 2). The PVI parameters were compared among the three groups. Results The success rates of the first‐pass isolation were comparable between the EC‐negative and EC‐positive groups (70.6% vs. 60.9%, ns), but the success rate was significantly higher in the on‐the‐line group than in the inside‐line group (91% vs. 20%, p = 0.002). First‐pass isolation was successful in both patients in the outside‐line group. Additional carina ablation was required only in the inside‐line group. Conclusions The association between the EC site and the right‐sided PV anterior isolation line affected the success rate of first‐pass isolation. For successful right‐sided PVI, it is important to consider the EC site when designing the PVI line.

Acute pulmonary vein stenosis during radiofrequency catheter ablation for atrial fibrillation

“…The optimal location of PV isolation line is a matter of concern. Recent literature has highlighted the presence of epicardial connections of PVs in certain cases, which has led to difficulties in successful PV isolation 4,5 . Ishikura et al.…”

“…Recent literature has highlighted the presence of epicardial connections of PVs in certain cases, which has led to difficulties in successful PV isolation. 4,5 Ishikura et al reported a low success rate of first-pass isolation in cases with a broader isolation area encompassing an exit site in the left atrium of the epicardial connection, as identified by activation mapping during sinus rhythm. 4 Although segmental ablation on the PV side facilitates complete PV isolation, it increases the risk of PV stenosis.…”

“…4,5 Ishikura et al reported a low success rate of first-pass isolation in cases with a broader isolation area encompassing an exit site in the left atrium of the epicardial connection, as identified by activation mapping during sinus rhythm. 4 Although segmental ablation on the PV side facilitates complete PV isolation, it increases the risk of PV stenosis. Furthermore, the epicardial connection sites in the right PVs are frequently located in the carina, necessitating additional carina ablation.…”

Detection of Epicardial Connection Through Intercaval Bundle Involving Right Pulmonary Veins After Ipsilateral Circumferential Ablation by Intra‐Atrial Activation Sequence Pacing From the Right Pulmonary Vein

“… 9 Among ECs, EC through the intercaval bundle (EC‐ICB) may need a carina ablation for PV isolation and reduce the acute and chronic success of PV isolation. 2 , 10 , 11 , 12 , 13 , 14 The carina ablation may increase the risk of PV stenosis 15 and phrenic nerve injury; 16 , 17 therefore, avoiding the carina ablation if possible would be better.…”

Very high power short duration ablation: It takes two to make a thing go right?

“…The frequency and risk factors for the feared complications related to ablation, like steam pop, cardiac perforation, or esophageal injury, are not well understood for vHPSD 5 . Early clinical studies of vHPSD ablation reported first pass PVI in approximately 50% of cases, while first pass PVI was achieved in greater frequency with both conventional and HPSD RF ablation using recently described approaches such as the “CLOSE Protocol.” 5–7 First pass isolation has been shown to be a powerful predictor of procedural efficacy, 3,8,9 thus a greater understanding of the underlying biophysics of lesions created with vHPSD RF ablation may inform optimization of timing and spacing to further improve outcomes for this new technology.…”