Techniques for the provocation, localization, and ablation of non–pulmonary vein triggers for atrial fibrillation Pasquale Santangeli, MD, PhD, Francis.

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Presentation transcript:

Techniques for the provocation, localization, and ablation of non–pulmonary vein triggers for atrial fibrillation Pasquale Santangeli, MD, PhD, Francis E. Marchlinski, MD, FHRS Heart Rhythm Volume 14, Issue 7, Pages 1087-1096 (July 2017) DOI: 10.1016/j.hrthm.2017.02.030 Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 1 Diagram showing the prevalence and distribution of sustained non–pulmonary vein triggers in patients with paroxysmal (PAF), persistent (PERS), and long-standing persistent (LS PERS) atrial fibrillation (AF) undergoing first time ablation. Adapted from Santangeli et al.5 Heart Rhythm 2017 14, 1087-1096DOI: (10.1016/j.hrthm.2017.02.030) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 2 Right anterior oblique (RAO) and left anterior oblique (LAO) fluoroscopic views illustrating the standard catheter position for trigger mapping. Heart Rhythm 2017 14, 1087-1096DOI: (10.1016/j.hrthm.2017.02.030) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 3 Suggested stepwise algorithm for localization of the origin of triggers from non–pulmonary vein atrial fibrillation based on the PW morphology of the 12-lead ECG. CS = coronary sinus; CT = crista terminalis; ECG = electrocardiogram; ER = Eustachian ridge; Inf = inferior; LA = left atrial; LAA = left atrial appendage; Lat = lateral; LOM = ligament of Marshall; MA = mitral annulus; Med = medial; PW = P wave; RA = right atrial; RAA = right atrial appendage; Sept = septal; SR = sinus rhythm; Sup = superior; TA = tricuspid annulus. Heart Rhythm 2017 14, 1087-1096DOI: (10.1016/j.hrthm.2017.02.030) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 4 Example of a trigger from the superior vena cava (SVC). Note earliest activation at the distal bipoles of the crista terminalis/SVC decapolar catheter, with reversal of activation between the far-field right atrial signal and the near-field SVC potential, with the beat initiating atrial fibrillation (arrows indicate direction of activation; see text for details). Heart Rhythm 2017 14, 1087-1096DOI: (10.1016/j.hrthm.2017.02.030) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 5 Diagram representing the possible sites of origin of non–pulmonary vein atrial fibrillation triggers according to earliest activation recorded at the coronary sinus (CS) catheter. CS = coronary sinus; LA = left atrial; LAA = left atrial appendage; LOM = ligament of Marshall; MA = mitral annulus; os = ostium. Heart Rhythm 2017 14, 1087-1096DOI: (10.1016/j.hrthm.2017.02.030) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 6 Example of an atrial fibrillation trigger from the CS body (arrow). Abl = ablation; CS = coronary sinus; CR = crista terminalis; d = distal; p = proximal. Heart Rhythm 2017 14, 1087-1096DOI: (10.1016/j.hrthm.2017.02.030) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 7 Example of a trigger from the left atrial septum directly recorded by the ablation catheter (arrow). Note the almost simultaneous activation of the CS and crista terminalis/superior vena cava decapolar catheters. Abl = ablation; CS = coronary sinus; CR = crista terminalis; d = distal; p = proximal. Heart Rhythm 2017 14, 1087-1096DOI: (10.1016/j.hrthm.2017.02.030) Copyright © 2017 Heart Rhythm Society Terms and Conditions