Atrial fibrillation originating from persistent left superior vena cava

© 2004 American Heart Association, Inc.BackgroundThe left superior vena cava (LSVC) is the embryological precursor of the ligament of Marshall, which has been implicated in the initiation and maintenance of atrial fibrillation (AF). Rarely, the LSVC may persist and has been associated with some organized arrhythmias, though not with AF. We report 5 patients in whom the LSVC was a source of ectopy, initiating AF.Methods and resultsIn 5 patients (4 men; age, 46+/-11 years) with symptomatic drug-refractory AF, ectopy from the LSVC resulting in AF was observed after pulmonary vein isolation. The ectopics were spontaneous in 2 and induced by isoproterenol in the others and preceded P-wave onset by 67+/-13 ms. During multielectrode or electroanatomic mapping, venous potentials were recorded circumferentially at the proximal LSVC near its junction with the coronary sinus (CS), but at the mid-LSVC level, they were recorded only on part of the circumference. The LSVC was electrically connected to the lateral left atrium (LA) and through the CS to the right atrium, with 4.1+/-2.3 CS-LSVC and 1.6+/-0.5 LA-LSVC connections per patient. Catheter ablation in the LSVC targeting these connections resulted in electrical isolation in 4 of the 5 patients without complications. After 15+/-10 months, the 4 patients with successful isolation, including 1 who had successful reablation for LA flutter, remained in sinus rhythm without drugs.ConclusionsThe LSVC can be the arrhythmogenic source of AF with connections to the CS and LA. Ablation of these connections resulted in electrical isolation.Li-Fern Hsu; Pierre Jaïs; David Keane; J. Marcus Wharton; Isabel Deisenhofer; Mélèze Hocini; Dipen C. Shah; Prashanthan Sanders; Christophe Scavée; Rukshen Weerasooriya; Jacques Clémenty; Michel Haïssaguerr

Reverse remodeling of sinus node function after catheter ablation of atrial fibrillation in patients with prolonged sinus pauses

© 2003 Lippincott Williams & WilkinsBACKGROUND: Symptomatic prolonged sinus pauses on termination of atrial fibrillation (AF) are an indication for pacemaker implantation. We evaluated sinus node function and clinical outcome in patients with prolonged sinus pauses on termination of arrhythmia who underwent ablation of paroxysmal AF. METHODS AND RESULTS: Twenty patients with paroxysmal AF and prolonged sinus pauses (> or =3 seconds) on termination of AF underwent ablation between May 1995 and November 2002. Patients with sinus pauses independent of episodes of AF were excluded from the analysis. The procedure included pulmonary vein and linear atrial ablation. After ablation, sinus node function was assessed during the first week and at 1, 3, and 6 months, by 24-hour ambulatory monitoring to determine the mean heart rate and heart rate range, and by exercise testing to determine the maximal heart rate. Corrected sinus node recovery time was determined at the completion of ablation and at 24.0+/-11.3 months at 600 and 400 ms. After AF ablation, there was a significant improvement of sinus node function, with an increase in the mean heart rate (P=0.001), maximal heart rate (P<0.0001), and heart rate range (P<0.0001). The corrected sinus node recovery time decreased in all patients evaluated at 600 ms (P=0.016) and 400 ms (P=0.019). At 26.0+/-17.6 months, 18 patients (85%) had no recurrence of AF (in the absence of medication), with no symptoms attributable to bradycardia or sinus pauses on ambulatory monitoring. Two patients had infrequent episodes of AF, 1 requiring pacemaker implantation. CONCLUSIONS: Prolonged sinus pauses after paroxysms of AF may result from depression of sinus node function that can be eliminated by curative ablation of AF. This is accompanied by improvement in parameters of sinus node function, suggesting reverse remodeling of the sinus node.Mélèze Hocini, Prashanthan Sanders, Isabel Deisenhofer, Pierre Jaïs, Li-Fern Hsu, Christophe Scavée, Rukshen Weerasoriya, Florence Raybaud, Laurent Macle, Dipen C. Shah, Stéphane Garrigue, Philippe Le Metayer, Jacques Clémenty, and Michel Haïssaguerr