Korean Circ J.  2014 Sep;44(5):291-300. 10.4070/kcj.2014.44.5.291.

How to Achieve Complete and Permanent Pulmonary Vein Isolation without Complications

• Han S
• Hwang C

• KMID: 2223867
• DOI: http://doi.org/10.4070/kcj.2014.44.5.291

Abstract

The efficacy and safety of catheter ablation for the management of atrial fibrillation (AF) has been improved in recent years. Radiofrequency (RF) catheter ablation for maintaining sinus rhythm is superior to the current antiarrhythmic drug therapy in selected patients. Pulmonary vein isolation (PVI) is the cornerstone of various catheter ablation strategies. It is well recognized that pulmonary vein (PV) antrum contributes to the AF initiation and/or perpetuation. Since PV stenosis is a complication of ablation within a PV, the ablation site for PVI has shifted to the junction between the left atrium and the PV rather than the ostium of the PV. However, PV reconnection after ablation is the major cause of recurrence of AF. The recovery of PV conduction could be caused by anatomical variations such as the failure to produce complete transmural lesion or gaps at the ablation line due to the transient electrophysiologic effects from the RF ablation. In this review, we discussed several factors to be considered for the achievement of the best PVI, including clinical aspects and technical aspects.

Keyword

Atrial fibrillation; Catheter ablation, radiofrequency; Pulmonary veins; Isolation

MeSH Terms

Atrial Fibrillation
Catheter Ablation
Constriction, Pathologic
Drug Therapy
Heart Atria
Humans
Pulmonary Veins*
Recurrence

Figure

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  Fig. 1 Three-dimensional reconstructed images of a left atrium. A and B: the left atrium of a patient with Pectus Excavatum. A shows the relationship between the ascending aorta and the left atrial anterior wall. B shows the indentation of the anterior wall by the aorta and the flattening of the left atrium. C and D: the left atrium of a patient with Marfan syndrome, which shows significant indentation of the posterior wall by the vertebral column.

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  Fig. 2 The proximity of esophagus to the left pulmonary veins. The line on A shows the location of the esophagus during the CT imaging, which was located close to the ablation line (B). Continuous ablation was done in the left lateral ridge, superior, inferior, and carina of the ridge side (C). Afterwards segmental isolation of the pulmonary veins was performed following the earliest activation site of the pulmonary veins to avoid possible esophageal injury (D).

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  Fig. 3 Images of hiatal hernia of a stomach. A and B: the thoracic portion of the stomach (arrow) has very close contact to the posterior wall of the left atrium on CT images. C and D show 3-dimensional relationship between the herniated stomach (arrow) with the esophagus and the left atrium.

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  Fig. 4 Anatomical characteristics of the junction of left atrium and pulmonary vein. A: microscopic appearances of myocardial sleeves in a heart specimen. Topography of the myocardial sleeves extends along the pulmonary veins on the adventitial side. The layer of the left atrial myocardium is separated from the muscular media of the pulmonary veins by a plane of fibro-fatty tissue. B: gross appearances of myocardial sleeves around pulmonary veins. The dotted lines indicate the junction between the left atrial myocardium and the pulmonary veins revealing complete continuity. C: three-dimensional reconstruction of a cross-section, perpendicular to the long axis of part of the wall of a myocardial sleeve covering a pulmonary vein, distal to the venoatrial junction (right to left). The direction of the muscle fibers is color coded. The venoatrial junction has heterogeneous orientation of the muscle fibers (Adapted from Saito T, Waki K, Becker AE. J Cardiovasc Electrophysiol 2000;8:888-94).14)

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  Fig. 5 The different transseptal puncture sites depend on the right inferior pulmonary vein anatomy. A shows typical anatomy of the right inferior pulmonary vein. Bottom picture shows the location of the transseptal puncture sheaths. B shows atypical location of the right inferior pulmonary vein, which projects far posteriorly and very close to the floor of the left atrium. Bottom figure shows a modified transseptal puncture according to the variation of pulmonary vein anatomy.

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  Fig. 6 A shows a right anterior oblique projection. B shows a left anterior oblique projection. It shows an anteroinferior and superoposterior double transseptal puncture. The two well-separated transseptal sheaths can provide various accesses to the pulmonary veins.

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  Fig. 7 Changes of electrogram by energy application. The sharp signal registered from the ablation catheter shows a loss of R wave progressively within 2 seconds after energy delivery (arrow), which implies that the catheter contact was good and the lesion formation by energy delivery was effective.

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  Fig. 8 Left Superior pulmonary vein mapping to identify the pulmonary vein ostium during sinus rhythm. Top picture is a left superior pulmonary venogram. Mid-row shows the location of the catheter ablation from the distal pulmonary vein to the anatomical ostium. Bottom row shows changes of the ablation electrograms according to the location. The signals from distal to mid pulmonary vein (arrows) show small single potential and later activation than the atrial activation. The signal from the electrical ostium shows high voltage multicomponent potentials with similar timing of the atrial activation. The signal of anatomical ostium has higher voltage with single component like a local atrial signal. PV: pulmonary vein, OS: ostium, Abl: ablation, HRA: high right atrium, d: distal, p: proximal.

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  Fig. 9 Designed ablation line on the merged 3-dimensional left atrium. AP: anteroposterior projection, RAO: right anterior oblique projection, PA: posteroanterior projection, LAO: left anterior oblique projection.

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