Key result
RF ablation of an epicardial connection eliminates unidirectional PV reconnection and prevents tachyarrhythmias for 3 years.
Why the study?
Epicardial connections via intercaval fibres connecting the right-sided PVs and RA can preclude isolation of right-sided PVs and occasionally possess unidirectional conduction properties.
Case Report (n=1)
No
Electrophysiologists should be aware of potential unidirectional reconnection of epicardial connections between the right atrium and right-sided pulmonary veins during AF ablation, which can be resolved by targeting the PV insertion.
Alerts clinicians to unidirectional epicardial reconnections in AF ablation; hypothesis-generating case leaves broader efficacy open.
Background: The epicardial connections (ECs) via intercaval fibres connecting the right-sided pulmonary veins (PVs) and right atrium (RA) can preclude isolation of the right-sided PVs. Such ECs occasionally have a unidirectional conduction property. Case summary: A 62-year-old man was referred to our institution for catheter ablation of paroxysmal atrial fibrillation (PAF). Circumferential antral PV isolation was performed via point-by-point radiofrequency (RF) applications. Thirty months after the ablation session, a recurrence of PAF was observed and a second procedure was performed. The right-sided PV was reconnected via an EC. Radiofrequency application at the RA insertion eliminated the EC. Thirty minutes thereafter, the right-sided PVs were reconnected. However, repetitive firings from the right-sided PVs did not conduct to the RA, indicating a unidirectional (RA to PV) reconnection of the EC, which was resolved by RF applications at the PV insertion. This time, the PV insertion of the EC was targeted and the unidirectional reconnection was successfully eliminated. The patient has remained free from any tachyarrhythmias for 3 years. Discussion: Although the mechanism of the unidirectional conduction property is unclear, source-sink mismatch and anisotropy are likely involved in the mechanism, as with accessory pathways. Electrophysiologists should be aware of the potential for unidirectional reconnection of ECs.
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Hasebe et al. (2024) conducted a case report in Paroxysmal atrial fibrillation (n=1). Radiofrequency catheter ablation was evaluated on Freedom from tachyarrhythmias. Radiofrequency ablation targeting the pulmonary vein insertion of an epicardial connection successfully eliminated a unidirectional reconnection, keeping the patient free from tachyarrhythmias for 3 years.
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