High density mapping guided partial antral ablation for a pulmonary vein isolation

Figures

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  Figure 1. Segments of the PVs. The left and right pulmonary veins are divided into 10 segments, respectively. The carinas are divided into superior and inferior segments.

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  Figure 2. Examples of a left superior pulmonary vein (LSPV) antral activation pattern (from (A) to (D), sequential according to the time), which shows a “directly activated from the LA” pattern. Activation mapping was performed during coronary sinus pacing. Each sub-figure is comprised of anterior and postero-superior views for the LSPV. (A) Most of the LSPV is not activated at this time and the activation is initiated from the ridge and carina. (B) After 17 ms, the antero-inferior segment, carina, and postero-inferior segment are activated first. (C) After 6 ms, the remaining postero-superior and antero-superior segments are activated. (D) After 8 ms, the entire antral level LSPV was activated. The site with the latest activation is the postero-superior PV, which is inside the PV and not at the antral level of the PV.

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  Figure 3. Examples of a left inferior pulmonary vein (LIPV) antral activation sequence according to the time [from (A) to (D)], which shows the presence of being “passively activated from an adjacent segment”. Activation mapping was performed during coronary sinus pacing. Each sub-figure is comprised of lateral and posterior views of the LIPV. (A) Most of the LIPV is not activated at this time, and the activation is initiated from the inferior ridge and inferior segment. (B) After 18 ms, the ridge segments are activated first. (C) After 6 ms, the carina segment is activated. (D) After 7 ms, the posterosuperior segment starts to activate. However, the postero-inferior segment is still not activated.

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  Figure 4. Examples of the ablation points in Figs. 2 and 3 (same patient). In this patient, the left superior pulmonary vein (PV) did not exhibit a passively activated segment. Therefore, a circumferential ablation at the PV antrum was performed (A). However, the left inferior (B) and right superior (C)/inferior (D) PVs exhibited passively activated segments, and an electrical isolation of the PVs was obtained only with a partial antral ablation (successful partial antral ablation). The red dots indicate a 30 W ablation. The green dots indicate a 25 W ablation. The blue dots indicate the isolation point.

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  Figure 5. Proportion of passively activated segments existing at each pulmonary vein antrum.