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(Circulation. 2002;105:e124.)
© 2002 American Heart Association, Inc.

Images in Cardiovascular Medicine

Pulmonary Vein Exit-Block During Radio-Frequency Ablation of Paroxysmal Atrial Fibrillation

Osnat Gurevitz, MD; Paul A. Friedman, MD

From the Division of Internal Medicine and Cardiovascular Diseases, Mayo Clinic, Rochester, Minn.

Correspondence to Paul A. Friedman, MD, Dept of Internal Medicine and Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail pfriedman{at}mayo.edu

A 34-year-old man with a history of labile hypertension was referred for focal ablation of paroxysmal atrial fibrillation (AF). The patient reported multiple episodes of palpitations since his late teens. Documentation of palpitations in the months preceding ablation had revealed AF. At electrophysiological study, there was no inducible supraventricular tachycardia, although dual AV nodal physiology was present. There was no evidence of an accessory pathway. During the study, AF developed. Cardioversion was attempted numerous times, with early recurrence of AF each time. Mapping of the initiating atrial beats postcardioversion revealed a focus in the right superior pulmonary vein (RSPV). Radio-frequency current was delivered to the ostium of the RSPV during AF. Exit-block developed between the pulmonary vein and the rest of the atria during energy delivery. Sinus rhythm was restored simultaneously. Figure 1 demonstrates the conversion from AF to sinus rhythm, while "fibrillatory activation" continues in the RSPV. Figure 2 shows spontaneous termination of pulmonary vein fibrillation 20 minutes after ablation. Although exit-block from the pulmonary veins is well-described, we believe this case to be unique because of the immediate restoration of sinus rhythm on achievement of exit-block. It demonstrates that pulmonary vein foci play a role not only in the initiation of atrial fibrillation, but also in its maintenance. Multiple attempts of programmed atrial stimulation after ablation did not reinitiate AF in this patient.

View larger version (26K): [in this window] [in a new window]   Figure 1. Conversion of atrial fibrillation to sinus rhythm on achievement of conduction block from the right superior pulmonary vein (RSPV) to the left atrium during energy delivery. Note the continuation of fibrillatory activity in the ostium of the RSPV. From top to bottom, Surface ECG lead V1 is displayed followed by bipolar intracardiac recordings from the high right atrium (HRA), poles 4,5 and 5,6 of the Lasso catheter positioned in the ostium of the RSPV (PV 4,5 and PV 5,6), and the ostium of the coronary sinus (CS Os).

View larger version (22K): [in this window] [in a new window]   Figure 2. Spontaneous termination of fibrillatory activity in the RSPV 20 minutes after ablation. Abbreviations same as in Figure 1.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gurevitz, O. Articles by Friedman, P. A. Search for Related Content PubMed PubMed Citation Articles by Gurevitz, O. Articles by Friedman, P. A. Related Collections Ablation/ICD/surgery Arrhythmias, clinical electrophysiology, drugs