Provocation and Localization of Arrhythmogenic Triggers from Persistent Left Superior Vena Cava in Patients with Atrial Fibrillation

Abstract

Background: Although pulmonary vein isolation (PVI) is an established procedure for atrial fibrillation (AF), non-PV foci play a crucial role in AF recurrence. Persistent left superior vena cava (PLSVC) has been reported as critical non-PV foci. However, the effectiveness of provocation of AF triggers from PLSVC remains unclear. This study was designed to validate the usefulness of provoking AF triggers from PLSVC. Methods: This multicenter retrospective study included 37 patients with AF and PLSVC. To provoke triggers, AF was cardioverted, and re-initiation of AF was monitored under high-dose isoproterenol infusion. The patients were divided into two groups: those whose PLSVC had arrhythmogenic triggers initiating AF (Group A) and those whose PLSVC did not have triggers (Group B). Group A underwent isolation of PLSVC after PVI. Group B received PVI only. Results: Group A had 14 patients, whereas Group B had 23 patients. After a 3-year follow-up, no difference in the success rate for maintaining sinus rhythm was observed between the two groups. Group A was significantly younger and had lower CHADS2-VASc scores than Group B. Conclusions: The provocation of arrhythmogenic triggers from PLSVC was effective for the ablation strategy. PLSVC electrical isolation would not be necessary if arrhythmogenic triggers are not provoked.

Atrial Fibrillation and Chronic Coronary Ischemia: A Challenging Vicious Circle

“…For patients with persistent forms of AF, it is more likely to have non-PV triggers, such as the left atrial posterior free wall [ 18 , 19 , 20 ], the left atrial appendage [ 21 ], the superior vena cava (young patients with AF had a higher incidence of only non-PV foci, mostly located here) [ 22 , 23 , 24 , 25 ], the coronary sinus [ 26 , 27 ], and the ligament of Marshall [ 28 , 29 ]. For non-PV foci patients, the isolation of them was a significant factor affecting the achievement of better clinical outcomes following AF ablation [ 30 ].…”