How to map and ablate a pulmonary vein–to–right atrium breakthrough during simultaneous persistent pulmonary vein fibrillation and organized atrial fibrillation using an automated high-resolution mapping system

摘要

A: Body surface and intracardiac electrograms during the atrial fibrillation (AF). The right pulmonary vein (PV) electrograms revealed disorganized activation and a shorter cycle length (CL) compared to the atrial electrograms recorded within the coronary sinus (CS), while the CS electrograms did not always reveal a stable CL and consistent activation sequence but revealed relatively organized activation. The numbers indicate the CLs measured in the CS. B: Automated atrial electrogram acquisition during the AF. During activation mapping, the beats that met all beat acceptance criteria were automatically acquired (green arrowheads), but those that did not meet any of the criteria were excluded (red arrowheads). The upper panels show whether each criterion was met or not: CL, CL variation (±70 ms); ΔR, activation timing difference between 2 reference electrodes (±5 ms); RSP, respiration gating; M, catheter motion per beat (<1 mm); S, catheter electrogram stability (0.25); TR, catheter tracking quality (<3). In the present case, the CL variation was manually set at ±70 ms, but the other parameters were the default values of the system. The bar became green if each criterion was met, and in contrast the bar became red if not. The middle panel shows the intracardiac electrograms recorded by the multielectrode catheter in the CS and the mini-basket catheter in the atrium. The numbers indicate the CLs measured by the reference electrode in the CS (CS 3-4). The lower panel shows the real-time curve of the CL, which fluctuated intensely between 210 and 430 ms. The green area in the lower panel indicates the acceptance threshold of the CL, and the upper and lower acceptance thresholds are 452 ms and 312 ms, respectively. If the CL was within the green area, the beat met the criterion of the CL variation, but if the CL was outside the green area, the beat did not. A4-5 to H4-5, mini-basket catheter recordings. CS1-2 to CS8-9, distal to proximal coronary sinus recordings. RIPV = right inferior PV electrograms recorded by a circular mapping catheter; RSPV = right superior PV electrograms recorded by the mini-basket catheter.