Isolating the Superior Vena Cava and Right Atrial Appendage by Pulsed Field Ablation

Figures

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  Figure 1. Mapping and Ablation in Patient 1 (A) The ablation lesions delivered by the Farawave catheter in each vein using the basket and flower shapes and in the posterior wall using the flower shape. (B) A sinus rhythm local activation time map created before ablation to document the distance from the sinus node to the ablation application sites at the superior vena cava (SVC) (10 mm) and the right atrial appendage (RAA) (17 mm). (C) Catheter positions and ablation lesions in the SVC and RAA.

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  Figure 2. Atrial Fibrillation Initiation in Patient 1 (A) After isolation of the pulmonary veins and posterior wall, the EZ Steer catheter was moved from coronary sinus to the high right atrium near the RAA (white catheter, Deca 1,2 to Deca 9,10), and the Farawave catheter (flower shape, Fara) was placed at the posterolateral mitral isthmus area before cardioversion. After cardioversion, atrial fibrillation recurred from the disorganized atrial activation in the right atrium at the lateral border of the RAA (yellow arrow at Deca 3,4). (B) During Farawave catheter manipulation from the SVC junction into the RAA, Fara 2,3 and Fara 3,4 were directed toward the RAA. A premature atrial contraction from the RAA originating at Fara 2,3 and Fara 3,4 triggered the atrial fibrillation (yellow arrows, originating from Fara 2,3 and Fara 3,4 from the RAA). Abbreviations as in Figure 1.

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  Figure 3. Premature Atrial Contractions in Patient 1 Frequent premature atrial contractions were recorded (A) from the SVC (yellow arrows) (Farapulse and Decapolar in SVC) and (B) from the RAA (yellow arrow) (Farapulse in SVC and Decapolar in RAA). Abbreviations as in Figure 1.

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  Figure 4. Ablation in Patient 1 (A) During SVC isolation, a nonsustained burst of atrial fibrillation was observed when ablation was applied at the SVC–RAA junction. (B) During the first application at the RAA, a nonsustained burst of atrial fibrillation, initiated by a premature atrial contraction from the RAA, was observed. The yellow arrows indicate the earliest activation at Fara 2,3 and Fara 3,4 within the RAA. (C) During the second application at the RAA, another nonsustained burst of atrial fibrillation was observed, again initiated by a premature atrial contraction from the RAA, indicating the origin at Fara 2,3 within the RAA, while the SVC remained isolated, as demonstrated by Deca 3,4 to Deca 9,10 (Deca 1,2 located at the arcuate ridge and Deca 3,4 to Deca 9,10 in the SVC). Abbreviations as in Figure 1.

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  Figure 5. Ablation and Atrial Fibrillation Initiation in Patient 2 (A) Atrial fibrillation initiated by a premature atrial contraction originating from the SVC recorded by the quadripolar catheter in the SVC. (B) SVC ablation applications resulted in an unorganized, fast atrial tachycardia originating from the RAA, similar to what was observed in the first patient. (C) After SVC isolation, pacing from Fara 5,1 inside the RAA triggered atrial fibrillation. Abbreviations as in Figure 1.