intracardiac echocardiography-guided, anatomically based radiofrequency ablation of focal atrial fibrillation originating from pulmonary veins
James Michael Mangrum, MD*,*,
James Paul Mounsey, BM, BCh, PhD, FACC*,
Lai Chow Kok, MBBS*,
John P. DiMarco, MD, PhD, FACC* and
David E. Haines, MD, FACC*
* Cardiovascular Division, Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
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Figure 1 Ectopic focus originating from within a pulmonary vein. (A) A premature atrial contraction originating from the right superior pulmonary vein (RSPV) is noted by the arrow. It precedes all other intracardiac recordings and surface P-wave. Additionally, within the vein there is distal to proximal activation. (B) An ectopic beat from the same vein serves as a trigger for atrial fibrillation. D = distal; DCS = distal coronary sinus; HALO = duodecapolar catheter in right atrium; LSPV = left superior pulmonary vein; MCS = middle coronary sinus; P = proximal; PCS = proximal coronary sinus.
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Figure 2 Intracardiac echocardiography (ICE) placed in left superior pulmonary vein (LSPV). An ablation catheter and ICE catheter are placed within the LSPV to guide radiofrequency ablation. (A) Fluoroscopic image of intracardiac catheters: duodecapolar catheter in right atrium with ICE and ablation catheter in LSPV. (B) Concomitant image from ICE visualizing the ablation catheter within the LSPV lumen.
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Figure 3 Positioning of the ablation catheter in the pulmonary vein. Intracardiac echocardiography (ICE) catheter is placed in the left superior pulmonary vein along with a 4-mm tip Blazer radiofrequency ablation catheter. The catheter can be seen within the lumen of the vein. The tip of the ablation catheter casts an echogenic shadow and allows precise location and apposition along the vessel wall. (A to D) Demonstrating catheter movement to the 12, 3, 6 and 9 o’clock positions.
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Figure 4 Electrical isolation of pulmonary vein (PV). Pacing threshold from within the PV was determined before ablation. After the intracardiac echocardiography (ICE)-guided circumferential lesions were created, pacing thresholds were again determined. Electrical isolation was defined by dissociation of an ectopic focus from within the vein or loss of PV potentials with pacing threshold distal to the ablation line exceeding 20 mA. (A) An ectopic focus is noted within the vein but does not conduct into the atria and is dissociated from the sinus rhythm. (B) Pacing from within the vein distal to the ablation line at 20 mA fails to conduct to the atria. DCS = distal coronary sinus; HALO = duodecapolar catheter in right atrium; MAP D = distal bipolar of mapping catheter; MAP P = proximal bipolar of mapping catheter; MCS = middle coronary sinus; PCS = proximal coronary sinus.
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Figure 5 Acute changes in pulmonary vein with radiofrequency ablation. A reduction in luminal area can be seen immediately after radiofrequency ablation. There is increased echogenicity in the vessel wall along with thickening. (A) Pre-ablation of a right superior pulmonary vein. (B) Immediately after ablation. RPA = right pulmonary artery; SVC = superior vena cava.
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