Recurrent Atrial Arrhythmia After Minimally Invasive Pulmonary Vein Isolation for Atrial Fibrillation Yaping Zeng, MD, Yongqiang Cui, MD, Yan Li, MD,

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Recurrent Atrial Arrhythmia After Minimally Invasive Pulmonary Vein Isolation for Atrial Fibrillation Yaping Zeng, MD, Yongqiang Cui, MD, Yan Li, MD, Xinpeng Liu, MD, Chunlei Xu, MD, Jie Han, MD, Xu Meng, MD The Annals of Thoracic Surgery Volume 90, Issue 2, Pages 510-515 (August 2010) DOI: 10.1016/j.athoracsur.2010.04.063 Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Three-dimensional mapping of gaps in two pulmonary vein isolation (PVI) lesions. Activation map of gaps produced using the CARTO system during sinus rhythm. The red area represents the sites of earliest activation, followed by orange, yellow, green, and blue, and finally purple denotes the areas of latest activity. Thick red arrowheads indicate the acting orientation. (A) Red area represents gaps at the proximal end of a PVI lesion arising from the left superior pulmonary vein, spreading down to the left inferior pulmonary vein. (B) A gap originates from the distal end of a PVI lesion, spreading upward to the right superior pulmonary vein. (MA = mitral valve annulus.) The Annals of Thoracic Surgery 2010 90, 510-515DOI: (10.1016/j.athoracsur.2010.04.063) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Lasso electrocardiogram and coronary sinus electrocardiogram of a gap at the roof of a pulmonary vein isolation (PVI) lesion. (A) There are two loci at the pulmonary vein (PV) antrum area during pacing from the distal side of the coronary sinus: pulmonary vein potential (PVP) and pulmonary vein antral potential (PVAP). The PVP does not appear to be consistent, although in one beat, it was not the offender loci. The PVAP is a double potential recorded at a gap in the right inferior pulmonary vein (RIPV) at every heart beat. (B) Both PVP and PVAP disappeared after ablation of the gap. The Annals of Thoracic Surgery 2010 90, 510-515DOI: (10.1016/j.athoracsur.2010.04.063) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 CARTO three-dimensional mapping and ablation of atrial tachycardia and atrial flutter. Activation time related to a reference signal in the coronary sinus is displayed by different colors. Red represents the earliest sites of activity, followed by orange, yellow, green, and blue, and purple denotes the latest points of activity. Having red adjacent to purple indicates the presence of reentry. Arrowheads point to acting orientation. The red circle indicates mitral valve annulus. (A) Atrial tachycardia around the base of the left appendage, following the free wall of left atrium (LA) to anterior wall of LA to occlusive left appendage. (B) Atrial flutter related to the LA roof and spreading anticlockwise, following the anterior of LA to bottom of LA to posterior of LA to LA roof). Red dots denote ablation at the roof between both superior pulmonary veins and complex fractionated atrial electrograms (CFAE) ablation. (C) Atrial flutter around the mitral valve annulus, activating clockwise following the free wall of LA to bottom of LA. Blue dots denote CFAE at the septum of LA, and red dots represent CFAE at the isthmus between right inferior pulmonary vein and mitral valve annulus along the septum of the LA. Light purple lesions preside at the coronary sinus. The Annals of Thoracic Surgery 2010 90, 510-515DOI: (10.1016/j.athoracsur.2010.04.063) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Method to reduce gaps. (A) Angulation between the electrodes and atrial tissue restricts involution of the two electrodes at the end of the two jaws. (B) Retreating the clamp backwards along the long axis of the pulmonary vein isolation lesion enables the elimination of developing proximal gaps. (C, D) Moving to both sides of the handle can reduce distant gaps. The Annals of Thoracic Surgery 2010 90, 510-515DOI: (10.1016/j.athoracsur.2010.04.063) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions