How to map and ablate a pulmonary vein–to–right atrium breakthrough during simultaneous persistent pulmonary vein fibrillation and organized atrial fibrillation using an automated high-resolution mapping system

Figures

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  Figure 1. A: Body surface and intracardiac electrograms during the atrial fibrillation (AF). The right pulmonary vein (PV) electrograms revealed disorganized activation and a shorter cycle length (CL) compared to the atrial electrograms recorded within the coronary sinus (CS), while the CS electrograms did not always reveal a stable CL and consistent activation sequence but revealed relatively organized activation. The numbers indicate the CLs measured in the CS. B: Automated atrial electrogram acquisition during the AF. During activation mapping, the beats that met all beat acceptance criteria were automatically acquired (green arrowheads), but those that did not meet any of the criteria were excluded (red arrowheads). The upper panels show whether each criterion was met or not: CL, CL variation (±70 ms); ΔR, activation timing difference between 2 reference electrodes (±5 ms); RSP, respiration gating; M, catheter motion per beat (<1 mm); S, catheter electrogram stability (0.25); TR, catheter tracking quality (<3). In the present case, the CL variation was manually set at ±70 ms, but the other parameters were the default values of the system. The bar became green if each criterion was met,…

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  Figure 2. Activation maps in the atria during the organized AF exhibited (A, B) a centrifugal pattern with the earliest activation on the right atrial septum and (C, D) conduction to the left atrium (LA) via the atrial septum (Online Video). The left and right panels show the LA and right atrium (RA) in the left anterior oblique view and the RA only in the left posterior oblique view, respectively. The gray tags are placed along the previous pulmonary vein isolation lines, and the white, light green, and light blue tags represent the earliest activation site (EAS) in the RA, LA site on the opposite side of the EAS in the RA, and EAS in the LA, respectively. The dark red and white arrows on the maps represent the activation wavefront and activation propagation, respectively. The numbers in the local electrograms indicate the intervals from the reference electrogram recorded in the coronary sinus (CS) to the local electrogram. The projection distance and confidence mask for the maps and online video were set at 2 mm and 0.03 mV, respectively. IVC = inferior vena cava; LAA = left atrial appendage; LSPV = left superior pulmonary vein; MA = mitral annulus; RSPV = right superior pulmonary vein;…

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  Figure 3. A, B: Entrance block from the atria to the right pulmonary veins (RPVs) (A) and exit block from the RPVs to the atria (B) were verified during sinus rhythm and RPV pacing. The black arrows on the electrocardiograms indicate the P waves during sinus rhythm. C: Final radiofrequency (RF) ablation sites with the postablation left atrial voltage map in the posteroanterior (left panel) and left anterior oblique (right panel) views. The yellow and pink tags represent the conduction gap and RF ablation sites along the superior box isolation line, respectively. The white and red tags represent the earliest activation site during the organized atrial fibrillation and RF ablation sites on the right atrial septum, respectively. RPV = right pulmonary vein. The other abbreviations are as in Figures 1 and 2.