Epicardial Connection as a Resource of Atrial Fibrillation Recurrence After Pulsed Field Ablation: A Case Report

Figures

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  FIGURE 1. The firing atrial rhythm. Activation map of spontaneous premature atrial contractions triggering atrial fibrillation. The earliest activation site was beneath the left common pulmonary vein (PV) ostium on the posterior wall; however, it was located slightly apart from the first PV isolation line. Although the premature atrial contractions were transiently suppressed by radiofrequency applications in this area, they failed to permanently eliminate the former.

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  FIGURE 2. The three‐dimensional electro‐anatomical mapping. Electro‐anatomical voltage mapping during pacing from the right atrium revealed the reconnection of the left pulmonary vein, with the anterior carina as the earliest reconnected site on ripple mapping, followed by the roof and floor, and then the posterior wall.

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  FIGURE 3. Reconstructed three‐dimensional electro‐anatomical mapping pacing on the reconnected region. (A) Electro‐anatomical mapping was reconstructed with pacing from the left common pulmonary vein (PV), the site with the earliest local activation time (LAT) corresponded to the previously identified, non‐eliminated premature atrial contractions (PACs) origin (▲). The yellow and white dotted lines indicate pathways predicted to represent epicardial conduction between the left anterior carina and the posterior PV ostium, which are presumed to involve the LOM or a left‐sided vein–atrium epicardial connection. Left PV isolation was completed by applying energy at the inferior portion of the anterior carina (▼). (B) To further delineate the conduction pathway, pacing was performed from four distinct sites within the left common PV (posterior bottom (①), posterior roof (②), anterior ostium (④), between anterior ostium and posterior roof (③)), and conduction times were measured from pacing sites to the distal coronary sinus electrode. The respective conduction times were measured as 140 ms, 138 ms, 118 ms, and 30 ms and the longest conduction times was observed from the posterior bottom site,…