Epicardial Connections as Intra-Atrial Conduction Routes in a Patient With Advanced Atrial Remodeling

Figures

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  Figure 1. Electrophysiological and Anatomical Findings at the Index Procedure (A) Left atrial activation map during sinus rhythm before ablation. The breakthrough site was at the anterior portion of the right superior pulmonary vein (RSPV) carina and antrum. The conduction time from the onset of the P-wave to the breakthrough site was 39 milliseconds. (B) The ablation line of the right-sided pulmonary veins crosses the breakthrough site. During ablation at the RSPV anterior roof (arrow), the PQ interval gradually prolonged, and transient atrioventricular block occurred. (C) Intracardiac electrograms before ablation show a normal PQ interval (155 milliseconds). (D) Intracardiac electrograms during radiofrequency (RF) application at the roof of the right-sided pulmonary veins. The PQ interval and the interval between onset of P-wave and atrial potential in the coronary sinus (P-Acs interval) were simultaneously prolonged, followed by a transient atrioventricular block. The intervals between the atrial and ventricular potentials in the coronary sinus (CS) (asterisks) were also prolonged. ABL = ablation catheter; d = distal; p = proximal; RIPV = right inferior pulmonary vein.

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  Figure 2. Electrophysiological and Anatomical Findings at the Second Procedure (A) Fluoroscopic images at the successful ablation at the right atrium (RA) and activation map of the right atrium during pacing from the right-sided pulmonary vein carina. Pacing was performed from the posterior side of the pulmonary vein to avoid direct capture of the right atrium. The conduction time between the pulmonary vein pacing and the earliest activation in the right atrium was 52 milliseconds. RF applications at the white and yellow tags successfully isolated the right-sided pulmonary veins. This successful ablation site was close to the sinus node (12 mm). (B) Intracardiac electrograms at the successful ablation site. The right pulmonary veins were isolated by ablation of the right atrium, indicating the presence of an epicardial connection. The PQ interval and the interval between onset of P-wave and atrial potential in the coronary sinus (P-Acs) interval were prolonged again, but the intervals between the atrial and ventricular potentials in the coronary sinus (CS) (asterisks) remained constant. See text for details. (C) Voltage map depicts the right atrium during sinus rhythm after pulmonary vein…

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  Figure 3. Schema Representing Electrical Propagation of Intra-Atrial Conduction in This Case See text for details. AVN = atrioventricular node; GP = ganglionated plexus; LVA = low-voltage area; RtPV = right-sided pulmonary vein; SN = sinus node; TV = tricuspid valve; other abbreviations as in Figures 1 and 2.