Atrial Fibrillation Begets Atrial Fibrillation in the Pulmonary VeinsOn the Impact of Atrial Fibrillation on the Electrophysiological Properties of the Pulmonary Veins in Humans
Thomas Rostock, MD*,
Daniel Steven, MD,
Boris Lutomsky, MD,
Helge Servatius, MD,
Imke Drewitz, MD,
Hanno Klemm, MD,
Kai Müllerleile, MD,
Rodolfo Ventura, MD,
Thomas Meinertz, MD and
Stephan Willems, MD
University Hospital Eppendorf, Department of Cardiology, Hamburg, Germany.
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Figure 1 Mean ERPs of the PVs and the Atria
Statistical comparison of the effective refractory periods (ERPs) of the atria and the pulmonary veins (PVs) (n = 139) before (Pre) and after (Post) the exposure to atrial fibrillation. LA = left atrium; RA = right atrium.
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Figure 2 Assessment of PV ERP by Programmed Stimulation
(Top) Fluoroscopic view of the catheter setting during a programmed stimulation of a left superior pulmonary vein (LSPV). The circumferential mapping catheter (Lasso [LS]) is placed at an ostial position of the LSPV while the ablation catheter (Map) is placed distally from the Lasso catheter within the LSPV. (Middle and bottom) Intracardiac tracings of the programmed stimulation within the LSPV after the exposure to atrial fibrillation (catheter setting as mentioned above). Stimulation is conducted through the ablation catheter (Map). The stimulation is performed with a basic drive cycle length of 440 ms, and a single extrastimulus is automatically decremented in steps of 10 ms until reaching the ERP. (1) At a coupling interval of 280 ms, the delay between S2 and the atrial farfield potential (AFF) is 140 ms. This delay continuously increases with further shortening of the extrastimulus coupling interval with a maximal increment of 300 ms induced by programmed stimulation with the shortest coupling interval with local capture of the PV musculature (S1/S2 to 110 ms). Of note, the S2 to PV potential interval also increases with shortening of the coupling interval. The ERP of the LSPV is reached at a coupling interval of 100 ms, which is markedly shorter as compared with the ERP before the atrial fibrillation exposure (250 ms). CS = coronary sinus; HRA = high right atrium; PVP = pulmonary vein potential; II, III, and V1 = surface electrocardiogram leads; other abbreviations as in Figure 1.
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Figure 3 Induction of AF by Programmed Stimulation
Programmed stimulation with a pulmonary vein after the presence of short-lasting atrial fibrillation (AF). The extrastimulus with a coupling interval of 140 ms induces AF (indicated by an asterisk), which is characterized by a complex fractionation and a short AF cycle length during the initial beats (145 ms), which is markedly faster than the AF cycle length of the atria (CS = 230 ms, HRA = 210 ms). Abbreviations as in Figure 2.
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Figure 4 Induction of AF by PV Stimulation
Tracing illustrating the approach of programmed stimulation in a pulmonary vein (PV) after the presence of atrial fibrillation (AF). The first baseline stimulus induces AF with a markedly shorter AF cycle length in the vein as compared with the atria. Of note, the first baseline stimulus is responded by a normal PV potential. After a delay of 150 ms, a "PV echobeat" (indicated by an asterisk) from the same vein occurred with a precocity of 180 ms and 205 ms to the following CS and HRA potential, respectively, that starts AF in the vein. Abbreviations as in Figure 2.
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