The Junction Between the Left Atrium and the Pulmonary Veins

Nathan, Hílel; Eliakim, M

doi:10.1161/01.cir.34.3.412

Cited by 384 publications

(226 citation statements)

References 39 publications

(7 reference statements)

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“…These reports confirm the hypothesis that the pathophysiology of AF can involve a focal mechanism 10-14 originating inside the pulmonary veins [15][16][17][18] , which is amenable to RF catheter ablation. Furthermore, it cautions about the risk of pulmonary veins stenosis related to the procedure.…”

Section: Discussionsupporting

confidence: 84%

Radiofrequency catheter ablation in patients with atrial fibrillation

Scanavacca¹,

Sosa²,

d’Ávila³

et al. 1999

Arq. Bras. Cardiol.

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this novel technique, as well as to caution against the risk of developing pulmonary veno-occlusive syndrome, observed in one patient submitted to radiofrequency catheter ablation.Case 1 -The first patient was a 36 year-old male who had presented with occasional episodes of paroxistic AF for the past ten years, and daily recurrences for the past two years. He had failed to respond to quinidine associated to digoxine, amiodarone, sotalol and subsequently propafenone associated to atenolol. After clinical and echocardiographic evaluation, no systemic or structural heart disease was documented. Rest ECG was normal, but ambulatory Holter monitoring displayed several episodes of non-sustained AF following atrial premature beats and frequent episodes of atrial tachycardia.In June, 1998, an EP study was undertaken under deep sedation with propofol, midazolam and fentanyl. Three catheters were inserted percutaneously into the right femoral artery. A decapolar catheter was positioned at the lateral wall of the right atrium. An octapolar catheter was inserted into the coronary sinus, and a quadripolar catheter with a 4 mm tip was inserted in the left atrium, through a transeptal approach ( fig. 1). An intravenous bolus of heparin (5000 IU) was given, followed by a 1000 UI/hr continuous infusion.AF was recorded in left atrial electrograms, whereas right atrium electrograms were organized and regular ( fig. 2). Three direct current shocks (200 J) were delivered in an attempt to restore sinus rhythm, but that was maintained for only a few seconds, with AF recurrence (fig. 3). With the catheter positioned at the right inferior pulmonary vein, we observed that AF initiated after an atrial premature beat occurring earlier at that site when compared to the right atrial and coronary sinus signals. However, it did not precede peripheral P wave. The catheter was subsequently manipulated towards the left superior pulmonary vein (LSPV) ostium and another direct current 200 J shock delivered. After AF recurred, it could be observed that the atrial beat initiating the tachycardia was about 100 msec earlier at this site than the P wave preceding the tachycardia (fig. 4). A Recent reports have demonstrated that, in some patients, atrial fibrillation is triggered by ectopic foci originated from the pulmonary veins and that these foci can be effectively treated by radiofrequency pulses. In this report we confirm these findings in three patients with paroxistic atrial fibrillation refractory to antiarrhythmic drugs, while we caution against the occurrence of pulmonary veno-occlusive syndrome, observed in one of the patients after the second attempt to treat atrial fibrillation with RF ablation. We concluded that although RF pulses are effective to interrupt focal atrial fibrillation, multiple applications in the pulmonary veins can produce significant pulmonary vein stenosis. The significance of these findings remains to be determined after a longer follow-up.Atrial fibrillation (AF) is one of the most frequently found cardiac arrhythmia in...

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Section: Discussionsupporting

confidence: 84%

Radiofrequency catheter ablation in patients with atrial fibrillation

Scanavacca¹,

Sosa²,

d’Ávila³

et al. 1999

Arq. Bras. Cardiol.

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“…70 Myocardial muscle fibers extend from the LA into all the PVs for 1–3 cm; the thickness of the muscular sleeve is highest at the proximal ends (1–1.5 mm), and then gradually decreases distally. 16,64,71 The orientation of the major atrial muscular bundles (e.g., Bachmann’s bundle or Crista terminalis) has been recognized from anatomical dissections, with mostly circular bundles around the ostia of the PVs, AV valves, and LAA.…”

Section: Section 2: Definitions Mechanisms and Rationale For Af Ablmentioning

confidence: 98%

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

Calkins,

Kuck,

Cappato

et al. 2012

Heart Rhythm

1,765

1,468

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“…This likely relates to the anatomic transition from pulmonary vein endothelium to left atrial endocardium; at this juncture, 2 types of tissue with different electric properties are juxtaposed, and this may potentiate development of AF. 15,33 In addition, autonomic nerves in these regions may contribute to the pathogenesis of AF. 34 Catheter ablation of the posterior left atrium, including the antra surrounding the pulmonary veins, has proven effective at ablating both paroxysmal and permanent AF.…”

Section: New Approaches For Surgical Af Ablationmentioning

confidence: 99%

Advances in Surgical Treatment of Atrial Fibrillation

Gillinov

2007

Stroke

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Abstract-Atrial fibrillation (AF) is the most common sustained arrhythmia. It is associated with increased risks of death and stroke; most strokes in AF patients are thought to arise from thrombi in the left atrial appendage. Surgical ablation of AF includes excision of the left atrial appendage and is an effective means of treating this arrhythmia, with the classic Maze procedure curing AF in Ͼ90% of patients and virtually eliminating the risk of late stroke. A complex but safe operation, the Maze procedure has been applied by relatively few surgeons. Americans; this number is expected to increase to Ͼ5.6 million by 2050. 1 The prevalence of AF increases with increasing patient age, and recent data from the Framingham Heart Study suggest that the lifetime risks for development of AF are 1 in 4 for men and women aged Ն40 years. 2 This epidemic has a growing impact on the healthcare system and a multibillion dollar cost. The clinical consequences of AF are well documented. AF is associated with reduced life expectancy and increases the risk of stroke 5-fold, accounting for Ϸ15% of all strokes nationally. 3-8 These AF-related strokes are a major challenge and a focus of several clinical trials investigating strategies for primary and secondary prevention. 4 Currently, antithrombotic therapy is the mainstay for stroke prevention in AF patients.Although there is currently some consensus concerning pharmacological strategies for stroke prevention in AF patients, choice of therapy for the heart rhythm is controversial and evolving. 9,10 Available antiarrhythmic therapies inconsistently restore sinus rhythm and are associated with complications. In fact, the risks associated with antiarrhythmic drug therapy may counterbalance the potential benefit of restoration of sinus rhythm. 9,10 These observations, coupled with increased understanding of the pathogenesis of AF, have resulted in the development of interventional strategies to restore sinus rhythm. Both catheter-based and surgical approaches have demonstrated effectiveness in this regard. Developed by Dr James Cox, the classic Maze procedure is the predicate operation for ablation of AF; long-term data suggest that the Maze procedure eliminates AF in Ͼ90% of patients. 11-14 Despite these unmatched results, the complexity and time associated with the Maze procedure have prevented widespread application by surgeons.Recently, however, there has been increased interest in direct surgical ablation of AF, fueled by technological advances and demonstration that the pulmonary veins and left atrium are the drivers of AF in most patients. 15 New ablation technologies enable surgeons to perform pulmonary vein isolation, create strategically placed, linear left atrial lesions, and excise the left atrial appendage rapidly and safely. 16 -23 Alternate energy sources used to create lines of conduction block and replace surgical incisions of the Maze procedure include radiofrequency, microwave, ultrasound, cryothermy, and laser. 16 -25 Applied primarily in patients with valvular...

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The Junction Between the Left Atrium and the Pulmonary Veins

Cited by 384 publications

References 39 publications

Radiofrequency catheter ablation in patients with atrial fibrillation

Radiofrequency catheter ablation in patients with atrial fibrillation

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

Advances in Surgical Treatment of Atrial Fibrillation

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