Electroanatomic mapping in atrioventricular junction ablation and pacemaker implantation for permanent atrial fibrillation associated with persistent left superior vena cava

Figures

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  Figure 1. Electroanatomic mapping (EAM) for right ventricular pacing lead placement. A: Anterior-posterior projection demonstrating maneuvering of the coronary sinus cannulation sheath into the right ventricle using the ablation catheter. B: Right anterior oblique (RAO) projection demonstrating refinement of the sheath position using a decapolar catheter. C: RAO projection of the EAM system reconstruction of the coronary sinus and persistent left superior vena cava (orange), right atrium (gray), and right ventricle (teal). The decapolar catheter is displayed. D: RAO projection demonstrating deployment of an active-fixation pacing lead through the sheath to the right ventricular septum.

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  Figure 2. Electroanatomic mapping (EAM) for atrioventricular junction ablation. The coronary sinus and persistent left superior vena cava are colored orange. EAM points indicate His bundle recordings (yellow), tricuspid annulus (teal), ablation lesions with no effect (red), ablation lesion #2 (green), and ablation lesion #5 (purple). See text for details. A: Left anterior oblique projection. B: Right anterior oblique (RAO) projection. C: Lesion #5 was 15.5 mm from the closest His bundle recording. Lesion #1, which did not have any effect, was delivered at the site of His bundle recordings. D: RAO cine image with the ablation catheter in the successful position, or lesion #5.

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  Figure 3. Ablation onset at the successful site, lesion #5 (purple dot in Figure 2), is demonstrated by an abrupt change on the ablation catheter recording and indicated by “Abl: ON” (boxed in red). A: The ablation catheter distal electrode (ABL d) recorded no atrial signals and low-amplitude ventricular signals. Recording speed 100 mm/second. B: An accelerated junctional rhythm appeared with ablation onset (red arrow). Complete heart block with pacing at 40 beats per minute occurred within 10 seconds (purple arrow). Recording speed 10 mm/second.