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Archives of cardiovascular diseases
Volume 111, n° 5
pages 340-348 (mai 2018)
Doi : 10.1016/j.acvd.2017.07.002
Received : 31 January 2017 ;  accepted : 29 July 2017
Clinical research

A novel method for localization and ablation of conduction gaps after wide antral circumferential ablation of pulmonary veins
Nouvelle méthode de localisation des gaps de conduction après ablation circonférentielle des veines pulmonaires
 

Figure 1




Figure 1 : 

Schemes showing different responses to pacing around the circumferential ablation lesions, and assumptions of gap localization. A. Superior and inferior pulmonary veins (PVs) were arbitrarily separated into eight different zones (1–8). The circular mapping catheter (CMC) was positioned in the PV with the shortest atrio-PV activation time (see “First step: positioning the CMC” for details). In this example, the CMC was positioned in a superior PV. For the following panels, pacing applied around the lesions (red dots) and responses to pacing (activation delays and sequences) for each point are shown. B. Pattern A: the activation delays converge towards a single point where the delay is the shortest (49ms), without any modification of the activation sequence; the presence of a single residual connection, in front of this pacing site, was assumed. C. Pattern B: the shortest activation delays converge towards two locations (41 and 51ms), without any change in the activation sequence, indicating the presence of two close gaps. D. Pattern C: the activation delays converge towards two remote locations (38 and 36ms), with a clear modification of the activation sequence recorded on the CMC, indicating the presence of two remote gaps. Inf: inferior; Sup: superior; WACA: wide antral circumferential ablation.


Figure 2




Figure 2 : 

Different responses to ablation of connection gaps. Tracings from top to bottom are surface electrocardiogram leads (I, II and V1) and intracardiac electrograms recorded from the catheter inside the coronary sinus (CS 1,2 to 9,10), the circular mapping catheter (CMC) (Lasso 1,2 to 19,20) and the ablation catheter (ABL 1–2 and 3–4). A. Presence of a single PV residual gap; the ablation to the targeted site resulted in complete PVI (arrows). B. Presence of two close PV gaps; an abrupt lengthening of the atrio-PV activation time from beat-to-beat (from 125 to 167ms), without any change in the activation sequence, was observed during ablation. In this example, the second connection was found to be 2cm away from the initial connection. C. Presence of two remote PV gaps; an abrupt lengthening of the atrio-PV activation time from beat-to-beat (from 139 to 154ms), with a change to the activation sequence in the CMC, was observed.


Figure 3




Figure 3 : 

Flowchart showing the different patterns found when using the pacing method in the study. EP: electrophysiological; PVI: pulmonary vein isolation; WACA: wide antral circumferential ablation.


Figure 4




Figure 4 : 

Example of the patternA. Posterior (panel A) and right anterior oblique (panel B) views of a three-dimensional shell of the left atrium reconstructed with the EnSite™ NavX™ System, in a patient referred for a redo ablation of atrial fibrillation. The wide antral circumferential ablation (WACA) lesion is depicted as the black line around the pulmonary veins (PVs). Electrograms recorded on the circular mapping catheter (located in the right inferior PV in this case) during pacing around the WACA lesion are shown in the boxes. Colour coding (from white to purple, i.e. early to late activation) was used to visualize the activation delays. One can appreciate the convergence of the activation delays, without any change in the activation sequence, towards a unique point in the posterosuperior region of the right WACA lesion. A unique residual connection was found and ablated (orange dots in panel A) to achieve PV isolation.


Figure 5




Figure 5 : 

Typical example of a pitfall of the technique, initially assuming the presence of two close gaps, whereas three gaps were eventually found. Posterior (panels A and B) and right anterior oblique (panel C) views of a three-dimensional shell of the left atrium reconstructed with the EnSite™ NavX™ System. The wide antral circumferential ablation (WACA) lesion is represented by the red dots. The circular mapping catheter (CMC) was placed in the right superior pulmonary vein (PV) (not shown in the three-dimensional map). Electrograms shown in boxes are recorded in the CMC where activation delays are the shortest. A. The electrogram recorded before ablation of the residual first connection. B. Before ablation of the residual second connection. C. Before ablation of the residual third connection. Pacing manoeuvres initially located gaps in the posterosuperior and posterior part of the WACA lesion. Ablating the more rapid connection () (shortest activation delay of 73ms in panel A), resulted in an abrupt lengthening of the activation delay, without any change in the activation sequence of the PV recorded in the CMC, confirming the presence of the close second gap. Pacing manoeuvres were then performed again to precisely locate the residual gap. Surprisingly, two different activation sequences were observed, one similar to the initial activation sequence with a longer delay at the site of the second connection, when pacing posteriorly to the WACA lesion (panel B, activation delay 100ms, bottom traces), and the second one more delayed when pacing anteriorly to the WACA lesion (panel B, top traces). This pattern is a typical response to the presence of two remote gaps. Ablating the posterior connection (, close to the first one) again resulted in an abrupt lengthening of the activation delay, with a change in the activation sequence of the PV recorded in the CMC. The last connection () was localized and ablated in the anterior part of the circular lesion, in a position diametrically opposed to the second gap (panel C). This last connection was probably masked because of its extremely slow conduction (207 vs. 73ms) and its relative proximity to the first connection compared with the second one, explaining how it was unmasked after removal of the first faster connection.

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