Provocation and ablation of non–pulmonary vein triggers in nonparoxysmal atrial fibrillation: Role of the coronary sinus

Figure 1. Electroanatomic voltage map of the left atrium in anteroposterior (A) and posteroanterior (B) views prior to ablation. A cut-off of bipolar voltage amplitude of <0.5 mV was used to define low-voltage areas.

Figure 2. A: Intracardiac recordings from the circular mapping catheter positioned at the level of the left atrial appendage ostium. B, C: Radiofrequency lesions were applied in order to target the earliest activation sites.

Figure 3. A, B: Further radiofrequency energy delivery to the left atrial appendage (LAA) terminated atrial fibrillation, restoring sinus rhythm and leading to LAA isolation. C: Fluoro image (anteroposterior) showing the circular mapping catheter positioned at the level of the LAA ostium and the ablation point (red star) where sinus rhythm was restored.

Figure 4. A: Following isoproterenol infusion, a focal atrial tachycardia (cycle length 280 ms) was seen with earliest activation in the proximal electrodes (B; red star) of the distal 20-pole catheter within the coronary sinus (CS). Our standard institutional protocol includes multiple catheters positioned with the following setup: (1) the 10-pole circular mapping catheter in the left superior pulmonary vein (PV) recording the far-field left atrial appendage activity; (2) the 20-pole linear catheter recording the superior vena cava, crista terminalis, and CS activity; (3) the ablation catheter in the right superior PV recording the far-field interatrial septum.

Figure 5. A: Radiofrequency applications to the proximal coronary sinus interrupted the atrial tachycardia. B: Fluoro image (anteroposterior) showing the ablation point (red star) where sinus rhythm was restored.

Figure 6. Complete isolation of the coronary sinus (CS) (B) was achieved with further ablation inside the CS (A; epicardial ablation), as well as from the left atrium (C; endocardial ablation). Red arrow: temperature probe.

Figure 7. A: Left atrial appendage (LAA) reconnection with delayed activation was documented via the circular mapping catheter positioned at the level of the LAA ostium. B: The LAA was subsequently reisolated.