Self-Reference and Atrial Pace Mapping With iPASO Identify Multiple Non-Pulmonary vein Triggers in Atrial Fibrillation.

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  Visual Summary. The Patient Exhibited Immediate Recurrence of AF1 Following Electrical Cardioversion Accordingly, self-reference mapping was performed to localize the non-pulmonary vein (PV) focus by sequentially tagging and updating the earliest activation on a 3-dimensional electroanatomical map using an OPTRELL catheter while advancing the catheter upstream, resulting in convergence of the tagged sites at a single overlapping point defining the trigger origin. The focus was identified at the anterior right pulmonary vein carina, and wide-area encircling ablation of right pulmonary veins restored sinus rhythm and eliminated immediate recurrence of atrial fibrillation (AF). After termination of AF1, a brief, self-terminating episode of AF (AF2) was observed. AF2 was similarly mapped to the inferior left atrial wall using self-reference mapping, and focal ablation at this site eliminated AF2 and prevented further AF initiation. Subsequently, intermittent premature atrial contractions were observed. The earliest atrial activation during premature atrial contractions was recorded at the proximal Halo catheter at the right atrial septum. Because premature atrial contractions were infrequent,…

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  Figure 1. The First Nonpulmonary Vein Trigger (AF1) and Voltage Map (A) The initial intracardiac electrogram showed atrial fibrillation (AF). Although direct current (DC) cardioversion was performed, AF recurred immediately, indicating immediate recurrence of AF. (B) Preablation voltage map revealed persistent isolation of the left pulmonary vein. Reconnection was observed in the right superior pulmonary vein, right inferior pulmonary vein, and right pulmonary vein carina. AP = anteroposterior view; CS = coronary sinus; dist = distal; Halo = Halo duodecapolar catheter; PA = posterior-anterior view; prox = proximal; RL = right-left; SR = sinus rhythm; V1 = lead V1.

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  Figure 2. Initiation of AF1 and Self-Reference Mapping for AF1 (A) Based on the findings of the first session, nonpulmonary vein triggers were suspected in the LAPW and right atrial septum. Mapping with the Halo catheter, the coronary sinus (CS) catheter, and the OPTRELL catheter (Biosense Webster) identified the earliest signal at electrodes E5 and E6 near the right pulmonary vein carina, prompting self-reference mapping. (B) Self-reference mapping was used to localize the nonpulmonary vein foci. The earliest activation site at atrial fibrillation initiation was identified using an OPTRELL catheter (Biosense Webster) and located at the anterior aspect of the right pulmonary vein carina. Gradual catheter advancement toward the EAS confirmed the origin. Extended right pulmonary vein isolation was performed, which successfully restored sinus rhythm and eliminated immediate recurrence of AF. The blue tag indicates the earliest activation site of the right pulmonary vein carina identified by self-reference mapping. AP = anteroposterior view; dist = distal; Halo = Halo duodecapolar catheter; LAO = left anterior oblique; prox = proximal; RA = right atrium; RL = right lateral; V1 = lead V1.

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  Figure 3. Initiation of the Second Nonpulmonary Vein Trigger (AF2) Arising from the Left Atrial Inferior Wall After eliminating the first nonpulmonary vein trigger, a second non-PV trigger (AF2) originating from a different site was observed. AF2 was a brief self-terminating episode of atrial fibrillation. Self-reference mapping using the OPTRELL catheter (Biosense Webster) positioned at the left atrial inferior wall identified the earliest activation at electrodes A1 and A2. The coupling interval was 200 ms. AP = anteroposterior view; CS = coronary sinus; dist = distal; Halo = Halo duodecapolar catheter; LAO = left anterior oblique; prox = proximal; PV = pulmonary vein; RA = right atrium; V1 = lead V1.

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  Figure 4. Identification of the Nonpulmonary Vein Trigger (AF2) Origin Using Self-Reference Mapping With the OPTRELL Catheter (Biosense Webster) The earliest activation site identified by the mapping catheter was tagged on a 3-dimensional electroanatomical map. (A to C) Then, the catheter was sequentially advanced upstream along the excitation path. The point at which the newly tagged earliest activation site precisely overlapped with the previous site corresponded to the origin of the nonpulmonary vein focus triggering atrial fibrillation. Ablation was performed at this site (D).

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  Figure 5. Short Run of Premature Atrial Contractions and Intracardiac Pace Match Scoring (iPASO) Mapping (A) Short burst of premature atrial contractions was observed. The earliest atrial activation was recorded at the proximal Halo positioned at the right atrial septum during the initiation of premature atrial contractions. The 3-dimensional image was obtained during electrogram recording while mapping the right atrium. (B) Because premature atrial contractions were infrequent, iPASO mapping was initiated around the right atrial septum. A high matching score of 0.75 was observed just above the fossa ovalis (FO). Based on this, an activation map was created in the surrounding region. The site with the highest iPASO coincided with the earliest activation site, confirming the origin of premature atrial contractions. Substrate modification was performed at this site. AP = anteroposterior view; CS = coronary sinus; dist = distal; Halo = Halo duodecapolar catheter; LAO = left anterior oblique; LAT = local activation time; PA = posteroanterior; prox = proximal; RA = right atrium.

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  Figure 6. Ablation Sites for Multiple Non-Pulmonary Vein Triggers and Follow-Up Data Obtained Via Remote Home Monitoring (A) A voltage map obtained after ablation along with the right posterior oblique view and right lateral view of all ablation sites in the left atrium and right atrium showed that additional lesions along the left atrial roof line and floor line successfully achieved left atrial posterior wall isolation. (B) Remote home monitoring over the course of 1 year confirmed complete elimination of atrial fibrillation (AF) and atrial tachycardia (AT) (AF burden: 0%) immediately after ablation. Sinus rhythm was sustained for more than 1 year despite discontinuation of all antiarrhythmic drugs. RL = right lateral; RPO = right posterior oblique.