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Circular mapping and ablation of thepulmonary vein for treatment of atrial fibrillation

Impact of different catheter technologies

Nassir F. Marrouche, MD^*, Thomas Dresing, MD^*, Christopher Cole, MD^*, Dianna Bash, RN^*, Eduardo Saad, MD^*, Krzysztof Balaban, MD^*, Stephen V. Pavia, MD^*, Robert Schweikert, MDFACC^*, Walid Saliba, MDFACC^*, Ahmed Abdul-Karim, MD^*, Ennio Pisano, MD, Raffaele Fanelli, MD, Patrick Tchou, MDFACC^* and Andrea Natale, MD^*,*

^* Section of Pacing and Electrophysiology, Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy

View larger version (112K): [in a new window]   Figure 1 Pullback mapping in a right upper pulmonary vein using the circular mapping catheter shown in panel A. One cm inside the vein (B), pulmonary vein potentials (PVPs) appeared barely present. Five mm from the ostium PVPs are recorded at T1, T2, T5, and T6 (C). Ultimately at the ostium, local pulmonary vein (PV) electrograms are seen at every bipole except T4 (D). After ostial isolation, requiring 19 lesions, no local ostial PV activity is observed (E). V1 and aVF represent surface electrocardiographic recordings. ESO = esophageal recording; hRA ds = high right atrium (hRA ds applies to Fig. 3C); CS = coronary sinus recording; T1–T6 = distal to proximal bipolar recordings from the circular catheter (CC). Continued on next page.

View larger version (48K): [in a new window]   Figure 2 Intracardiac recordings showing concealed premature atrial contraction (PAC), which eventually managed to activate the atrium and initiate AF. Differently from what we observed distally in the vein, ostial initiations appeared to have a more longitudinal activation sequence. Note simultaneous activation in T1, T2, T3, T6, and T7. Bipole T4 does not record any PVP, but appeared to correspond to the take off of a branch. See Figure 1 for abbreviations.

View larger version (94K): [in a new window]   Figure 3 Intracardiac recordings from the circular mapping catheter placed in the RUPV as shown in panel A. Deployment of the catheter 5 mm from the ostium demonstrated early local PV activation at the T5, T6 bipolar recordings (B). Distal isolation (C) was achieved with four lesions directed in the proximity of the T5, T6 segments. Note the absence of PVPs from T1 to T6 recordings on the circular catheter. However, AF is not yet abolished and appeared to originate more proximally. In this patient successful elimination of AF was obtained by ostial isolation. OCT1–OCT4 = distal to proximal longitudinal bipolar recordings. See Figure 1 for other abbreviations. Continued on next page.

View larger version (21K): [in a new window]   Figure 4 Atrial fibrillation free survival curves after pulmonary veins isolation in patients ablated with the 4-mm tip (dashed line), the 8-mm tip (dotted line), and the cooled-tip (solid line) catheter are shown. Recurrence rate appeared to be higher with the 4-mm tip catheter (p < 0.05).