Lessons from dissociated pulmonary vein potentials: entry block implies exit block

Duytschaever, Mattias; Meyer, Grim De; Aceña, Marta; Elhaddad, M.; Greef, Yves De; Heuverswyn, Frédéric Van; Vandekerckhove, Yves; Tavernier, René; Lee, Geoffrey; Kistler, Peter M.

doi:10.1093/europace/eus353

Cited by 34 publications

(25 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…However, only 1 of the 171 (0.6%) spontaneous potentials exited to the LA. 2 In our patient, 2 behaviors of dissociated spontaneous PV activity were present; the left superior PV exhibited the typical exit block, despite its capture by pacing, and the RSPV showed this unique rate-dependent exit PV-LA conduction. This raterelated conduction abnormality may share some mechanisms found to explain bradycardia-dependent conduction block in Purkinje tissue.…”

mentioning

confidence: 53%

Rate-Dependent Exit Conduction Block From Pulmonary Vein to Left Atrium After Entrance Block

Yagishita

Gimbel

Arruda

2016

Circ: Arrhythmia and Electrophysiology

View full text Add to dashboard Cite

P ulmonary vein electric isolation (PVI) is an effective therapy for atrial fibrillation. Bidirectional conduction block between left atrium (LA) and the pulmonary veins (PV) is an accepted end point for PVI. We report a case of rate-dependent unidirectional exit conduction from PV to LA after PVI by large area circumferential ablation, despite entrance and exit conduction block.A 63-year-old man with symptomatic paroxysmal atrial fibrillation refractory to flecainide underwent PVI. An 8-Fr irrigated ablation catheter (Thermocool RMT) connected to a CARTO3 (Biosense Webster, Diamond Bar, CA) electroanatomic mapping system and Stereotaxis remote navigation system were used for PVI. A circular mapping catheter was used to confirm electrogram-guided PVI by large area circumferential ablation. Isolation of the ipsilateral left PVs was obtained, and bidirectional conduction block between the left PVs and LA was confirmed. Subsequently, isolation of the right superior PV (RSPV) was noted by entrance conduction block. Of note, the left PVs and the RSPV exhibited dissociated spontaneous electric activity suggestive of exit conduction block (Figure 1). Pacing from the distal bipoles of the ablation catheter at the anterior aspect of the RSPV was performed at a cycle length of 600 ms (10 mV/2 ms). Pacing captured the PV by suppressing its dissociated activity and unexpectedly revealed exit conduction from the RSPV to LA. The same response was obtained by pacing the posterior aspect of the RSPV without changing the atrial activation sequence, which was earlier in the distal coronary sinus than the right atrium. This rate-dependent exit conduction was reproducible, and it was maintained irrespective of lowering the pacing output down to 1 mV, ruling out far-field capture of the superior vena cava. To further assess this rate-dependent unidirectional exit conduction, the cycle length was changed from 600 to 1500 ms and to 1000 ms. Despite PV capture at 1500 and 1000 ms, exit block persisted. However, by pacing at 600 ms, the rate-dependent exit conduction reappeared. Additional ablation along the RSPV large area circumferential ablation lesion set eliminated the rate-dependent exit conduction at baseline and during both adenosine and isoproterenol challenge (Figure 2).Weerasooriya et al demonstrated that dissociated spontaneous PV activity after PVI represented exit conduction block. Duytschaever et al showed spontaneous isolated PV activity in 171 PVs among 135 patients (35% of 378 patients). However, only 1 of the 171 (0.6%) spontaneous potentials exited to the LA.2 In our patient, 2 behaviors of dissociated spontaneous PV activity were present; the left superior PV exhibited the typical exit block, despite its capture by pacing, and the RSPV showed this unique rate-dependent exit PV-LA conduction. This raterelated conduction abnormality may share some mechanisms found to explain bradycardia-dependent conduction block in Purkinje tissue. Even though phase 4 depolarization was initially implicated, El-Sherif and Jalife have...

show abstract

mentioning

confidence: 53%

Rate-Dependent Exit Conduction Block From Pulmonary Vein to Left Atrium After Entrance Block

Yagishita

Gimbel

Arruda

2016

Circ: Arrhythmia and Electrophysiology

View full text Add to dashboard Cite

show abstract

“…One possible explanation for this finding is that pacing the circular mapping catheter at high output may directly capture the right atrium or LAA. This is also supported by the fact that only 0.6% of spontaneous PV potentials following circumferential PV isolation are conducted to the LA 2 . P-wave morphology and intracardiac activation sequence can be helpful in recognizing this phenomenon.…”

Section: Discussionmentioning

confidence: 91%

Absence of exit block due to direct capture of the left atrial appendage: A visual confirmation

Vroomen

Meir

Crijns

et al. 2016

HeartRhythm Case Reports

View full text Add to dashboard Cite

“…In the case of a slow PV rhythm or isolated PV ectopy, the documentation of exit block is more challenging, since advancement of LA activation by the dissociated PV potentials needs to be ruled out. [4]…”

Section: Discussionmentioning

confidence: 99%

Spontaneous Documentation of Bidirectional Block During Pulmonary Vein Isolation - Keep an Eye on the Electrograms!

Tzeis

Pastromas

Andrikopoulos

2013

Indian Pacing and Electrophysiology Journal

View full text Add to dashboard Cite

show abstract

Lessons from dissociated pulmonary vein potentials: entry block implies exit block

Cited by 34 publications

References 26 publications

Rate-Dependent Exit Conduction Block From Pulmonary Vein to Left Atrium After Entrance Block

Rate-Dependent Exit Conduction Block From Pulmonary Vein to Left Atrium After Entrance Block

Absence of exit block due to direct capture of the left atrial appendage: A visual confirmation

Spontaneous Documentation of Bidirectional Block During Pulmonary Vein Isolation - Keep an Eye on the Electrograms!

Contact Info

Product

Resources

About