The Superior Vena Cava As a Site of Ectopic Foci in Atrial Fibrillation

Pastor, Agustı́n; Núñez, Ambrosio; Magalhães, Ana Paula Moreira; Awamleh, Paula; García-Cosío, Francisco

doi:10.1016/s1885-5857(07)60108-x

Cited by 6 publications

(3 citation statements)

References 10 publications

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“…Although PV triggers remain the main source inducing AF, foci localized outside of the PV have been shown to trigger this arrhythmia . These are often found in the posterior wall and more proximally in the PV antrum, even though the superior vena cava has already been documented as an AF‐inducing source …”

Section: Discussionmentioning

confidence: 99%

Second‐Generation Cryoballoon Ablation in the Setting of Lone Paroxysmal Atrial Fibrillation: Single Procedural Outcome at 12 Months

Regibus¹,

Mugnai²,

Moran

et al. 2016

Cardiovasc electrophysiol

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Section: Discussionmentioning

confidence: 99%

Second‐Generation Cryoballoon Ablation in the Setting of Lone Paroxysmal Atrial Fibrillation: Single Procedural Outcome at 12 Months

Regibus¹,

Mugnai²,

Moran

et al. 2016

Cardiovasc electrophysiol

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“…The average success, recurrence and complication rates are 99.3 %, 18.5 %, and 1.9 %, respectively, for AF originating from the vena cava. 8,[43][44][45]74,[78][79][80][81][82][83][84][85][86][87][97][98][99][100][101][102][103][104][105][106][107][108][109][110][111] These rates are 78.0 %, 16.7 %, and 2.4 %, respectively, for AF originating from the Marshall ligament. 6,56,67,68,94,112,113 A higher incidence of recurrent AF and non-PV AF sources has been reported in patients with metabolic syndrome and obstructive sleep apnoea.…”

Section: Ablation Outcomesmentioning

confidence: 94%

Catheter Ablation of Paroxysmal Atrial Fibrillation Originating from the Non–Pulmonary Vein Areas

Higa¹,

Tai²,

Chen³

2005

Catheter Ablation of Cardiac Arrhythmias

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Catheter ablation of AF has become an established therapy and may have the potential to cure this most commonly encountered sustained arrhythmia. Previous studies have demonstrated that pulmonary veins (PVs) are a major source of the ectopic beats that initiate AF. PV isolation in patients with symptomatic paroxysmal AF refractory to antiarrhythmic drugs is effective; however, it is difficult to eliminate all instances of AF. [1][2][3] If ectopic foci consistently come from a non-PV area and a pattern of spontaneous onset of AF is onset confirmed, the earliest ectopic site is defined as the non-PV trigger initiating AF. 2,[4][5][6][7] Ectopy originating from non-PV areas can initiate AF and can cause it to recur after PV isolation. Non-PV ablation after multiple AF ablation procedures decreases the risk of recurrence and increases the cure rate. 10,[19][20][21]23,25,28,29 Although several ablation strategies have been developed, the outcomes of ablation are not improved unless substrate modification targets AF triggers. 30 Taking all of these considerations into account, non-PV ectopy plays important role in both AF initiation and recurrence. 2,[4][5][6][7]20,29,30,[32][33][34] Mapping studies of non-PV foci have revealed that triggers are often found in anatomically predictable regions, such as the left atrial wall, thoracic veins and crista terminalis, and can be sustained or non-sustained triggers of AF. These areas can be mapped by specific multielectrode catheters positioned in key regions and ablated after the AF is induced and localised, or they can be ablated empirically without the induction of ectopy. This review focuses on catheter ablation of AF initiated by non-PV triggers, summarising the electrophysiological characteristics, mapping and ablation strategies, their safety and efficacy. Electrophysiological Features of AF Originating from Non-pulmonary Vein Areas Incidence of InitiatorsSeveral important concepts have been proposed regarding the role of non-PV ectopy in initiating AF. 2,[4][5][6][7] AF is initiated by non-PV disturbance of the cardiac rhythm in up to 39 % of cases. 3,[8][9][10][32][33][34][35][36][37][38] The left atrium (LA) (25.3 %), superior vena cava (SVC) (22.2 %), coronary sinus (CS) (18.0 %), right atrium (RA) including the crista terminalis (17.4 %), interatrial septum (7.9 %), and ligament of Marshall (LOM) (3.9 %) are the areas in which non-PV triggers of de novo AF are most commonly found (Table 1), whereas the SVC, interatrial septum and LA are the most common non-PV trigger sites in recurrent AF (Table 2). Furthermore, there is a higher incidence of non-PV triggers initiating AF in females and in patients with an enlarged LA. 39 Pathophysiology Histological analysis of the embryonic sinus venosus has identified areas capable of spontaneous depolarisation at the junctions between different embryonic tissues, such as the RA-SVC junction, crista terminalis and CS ostium. [40][41][42] The SVC is a major origin of non-PV triggers of AF. 5,8,[32][33][34][43][44][45][46][47] H...

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“…Several previous studies showed PV-triggers and that AF triggers outside the PVs were located in the vena cavae, the crista terminalis, the coronary sinus, the ligament of Marshall, the inter-atrial septum, and the appendages. [34][35][36][37][38][39][40][41][42] The role of the PVs in the development and maintenance of AF was published by Haïssaguerre et al. Narayan et al, detected focal and rotor activity with spatial stability using low-resolution endocardial basket catheter and phase singularity AF mapping.…”

Section: Are Reentries Frequently Anchored Between Slow Conduction Zomentioning

confidence: 99%

Atrial Fibrillation Drivers: Redefining the Electrophysiological Substrate

Rottmann

Pfenniger

Yoo

et al. 2020

Preprint

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Background: We performed high-density mapping of persistent atrial fibrillation (AF) in animals and patients (1) to test that AF is due to greater than or equal 1 reentry, and (2) to characterize activation delay and reentries pre/ post pulmonary vein isolation (PVI). We determined electrophysiological characteristics that may predispose to the induction, maintenance, and reduction of AF. Methods and Results: This study includes 48 dogs and nine patients. 43 AF- and five sinus/ paced rhythm dogs (3-14 weeks rapid atrial pacing) were studied at open chest surgery with 117 epicardial electrograms (EGMs) (2.5mm dist.) in 6 bi-atrial regions. Rotational activity automatically detected with a new algorithm tracking the earliest and latest activation in all regions (5+/-2 per region) were stable over 424+/-505ms [120-4940ms]. Reentry stability was highest in the right atrial appendage (RAA) (405+/-219ms) and the posterior left atrium (PLA) (267+/-115ms) and anchored between >=3 zones of activation delay (15+/-5ms, median 13ms) defined as >10ms per 2.5mm. Cycle length (CL) and degree of focal fibrosis were highest in the PLA and left atrial free wall (LAFW) with 94+/-7ms, 96+/-5ms, and 49+/-14%, 47+/-19%. Fiber crossing density correlated with the stability of rotational activity (R=0.6, P<0.05). Activation delay was 2x higher in AF compared to sinus rhythm/paced rhythm (interval 200-500ms). Activation delay zones > 10ms were at the same locations, but increased 4x during AF vs. SR and were located at fiber crossings, fibrosis/ fat zones. Stability of rotational activity correlated with Organization Index (OI), Fraction Index (FI), Shannon's Entropy (ShEn), and CL (R>0.5, p< 0.0001). PVI in five hearts increased CL [2-14%] and reduced stability of rotational activity in nearly all regions remote to the pulmonary veins (PVs). Also in the clinical evaluation in nine patients using the HD-catheter (16 electrodes, 3mm dist.) activation delay at the reentrant trajectory was 2x higher at edges with maximal delay (20.5+/-8.1ms, median 19.6ms) vs (9.3+/-8.8ms, median 9.2ms) and 1.4 x higher during AF (13.0+/-18.7ms, median 7.2ms) compared to SR/ CS-pacing (18.0+/-11.6ms, median 17.7ms). Conclusion: Rotational activities in all bi-atrial regions anchored between small frequency-dependent activation delay zones in AF. PVI led to beneficial remodeling in bi-atrial regions remote to the PVs. These data may identify a new paradigm for persistent AF.

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The Superior Vena Cava As a Site of Ectopic Foci in Atrial Fibrillation

Cited by 6 publications

References 10 publications

Second‐Generation Cryoballoon Ablation in the Setting of Lone Paroxysmal Atrial Fibrillation: Single Procedural Outcome at 12 Months

Second‐Generation Cryoballoon Ablation in the Setting of Lone Paroxysmal Atrial Fibrillation: Single Procedural Outcome at 12 Months

Catheter Ablation of Paroxysmal Atrial Fibrillation Originating from the Non–Pulmonary Vein Areas

Atrial Fibrillation Drivers: Redefining the Electrophysiological Substrate

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