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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Localization of Atrial Fibrillation Triggers in Patients Undergoing Pulmonary Vein Isolation

Importance of the Carina Region

Ermengol Valles, MD^_*,, Roger Fan, MD^_*, Jean François Roux, MD^_*, Christopher F. Liu, MD^_*, John D. Harding, MD^_*, Sandhya Dhruvakumar, MD^_*, Mathew D. Hutchinson, MD^_*, Michael Riley, MD^_*, Rupa Bala, MD^_*, Fermin C. Garcia, MD^_*, David Lin, MD^_*, Sanjay Dixit, MD^_*, David J. Callans, MD^_*, Edward P. Gerstenfeld, MD^_* and Francis E. Marchlinski, MD^_*,_*

^_* Electrophysiology Section, Cardiovascular Division, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Universitat Autònoma de Barcelona, Barcelona, Spain

Manuscript received May 27, 2008; revised manuscript received June 23, 2008, accepted July 1, 2008.

^_* Reprint requests and correspondence: Dr. Francis E. Marchlinski, 9 Founders Pavilion, Hospital of University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104 (Email: francis.marchlinski{at}uphs.upenn.edu).

Objectives: This study sought to identify the origin within the pulmonary vein (PV) of reproducible atrial fibrillation (AF) triggers.

Background: Triggers for AF frequently originate from PVs. However, a systematic evaluation of the location of origin within the PV orifice and associated techniques for eliciting triggers has not been performed.

Methods: Spontaneous triggers and those provoked with isoproterenol (up to 20 µg/min) and/or cardioversion in 45 patients with AF were identified using multipolar catheter recordings. In identifying origin, PVs were divided into 17 equal segments from ipsilateral PVs with "carina zone" (CZ) (7 segments between the PVs) and 10 "noncarina zone" (NCZ) segments.

Results: Sixty-three reproducible triggers were noted in 37 of the 45 (82%) patients with 57 from PV and 6 (10%) from non-PV sites. Although triggers were identified from 26 of 34 distinct PV segments, most PV triggers (36, 63%) originated from CZ segments (p < 0.05) from both right (17 triggers) and left (19 triggers) PVs. The CZ triggers were more often spontaneous (11 of 36 in CZ vs. 2 of 21 in NCZ; p < 0.05) or elicited with CV (17 of 36 in CZ vs. 6 of 21 in NCZ; p < 0.05). In contrast, NCZ triggers were more likely to require isoproterenol to be provoked (13 of 21 [62%] vs. 8 of 36 [22%], p < 0.05).

Conclusions: Reproducible spontaneous and provoked PV triggers initiating AF can be observed in most patients undergoing AF ablation. These triggers most commonly originate from the carina region of both right and left PVs. Noncarina PV triggers more commonly require provocation with isoproterenol infusion.

Key Words: atrial fibrillation • catheter ablation • arrhythmia initiation

Abbreviations and Acronyms   AF = atrial fibrillation   CS = coronary sinus   CV = cardioversion   CZ = carina zone   LA = left atrium   NCZ = noncarina zone   PV = pulmonary vein   SVC = superior vena cava

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J. Am. Coll. Cardiol. 2008 52: A26. [Full Text] [PDF]