IMAGES IN ELECTROPHYSIOLOGY
doi:10.1093/europace/eur427
Online publish-ahead-of-print 20 February 2012
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Pulmonary veins firing simultaneously
Antonio Navarrete*
Indiana University Health-Ball Hospital, 2525 University Avenue, Muncie, IN 47304, USA
* Corresponding author. Tel: +1 765 281 2059; fax: +1 765 281 2534, Email: [email protected]
A 62-year-old man was referred for catheter ablation of symptomatic paroxysmal atrial fibrillation refractory to propafenone and dronedarone. Isoproterenol in doses of 1–5 mg/min was administered for testing purposes after the completion of pulmonary vein (PV)
Figure 1 (A) Pulmonary vein atrial tachycardia with exit block. Rapid atrial activity is seen at the
beginning of the trace within the right upper pulmonary vein (black arrows; A, atrial electrogram).
The ablation catheter (ABL) is positioned outside the right upper pulmonary vein. At the end of
the trace, a left atrial premature contraction initiated an atrial tachycardia with entrance block to
the right pulmonary vein. (B) Spontaneous termination of atrial tachycardia within the right upper
pulmonary vein (bold A, atrial electrogram recorded within the right pulmonary vein). Note the
continuation of atrial activity (blue A) within the coronary sinus and the ablation catheter without
affecting the pulmonary vein. Shown are leads I, AVF, V1, and intracardiac electrograms from a
circular twenty poles catheter placed at the right superior pulmonary vein (Lass 1-10), coronary
sinus (Cs1, distal; CS5,6, mid; Cs 9,10, proximal), an ablation catheter (ABLd,p) placed right
outside the pulmonary vein. P, p waves; A, atrial electrogram; V, ventricular electrogram; Ablation
d, ablation distal electrode; Ablation p, ablation proximal electrode. The pink area of the figure
corresponds to the electrograms within the upper right pulmonary vein and the blue area to electrograms from the coronary sinus and outside the pulmonary vein.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2012. For permissions please email: [email protected].
isolation guided by a 20-electrode circular mapping catheter. An atrial tachycardia within the right PV was observed during isoproterenol infusion (Panel A) with complete exit block to the rest of the atrium. During ongoing tachycardia a left atrial premature
beat (red asterisk) initiated an atrial tachycardia that degenerated into atrial fibrillation without affecting the right pulmonary vein
tachycardia (PV entrance block, Panel B). Termination of this PV tachycardia occurred spontaneously. The left atrial premature
beats were mapped to the left upper PV. Note that the PV electrograms were wide and fractionated with a slight difference in
their morphology probably due to a prior ablation around this vein. The left upper PV was then re-isolated. Neither PV tachycardia
nor atrial fibrillation could longer be induced despite isoproterenol administration and programmed atrial stimulation until reaching the
effective atrial refractory period. Isolation of the right upper pulmonary vein and left upper pulmonary vein remained after 60 min of
the last ablation and no additional lesions were delivered. Although PV tachycardia with exit block and PV ectopy triggering atrial fibrillation have been reported before, this is the first case to our knowledge of PVs firing at the same time: the right pulmonary vein
causing a PV tachycardia and the left pulmonary vein with premature atrial contractions inducing atrial fibrillation.