(Circulation. 1999;100:1879-1886.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Initiation of Atrial Fibrillation by Ectopic Beats Originating From the Pulmonary Veins
Electrophysiological Characteristics, Pharmacological Responses, and Effects of Radiofrequency Ablation
From the Division of Cardiology, National Yang-Ming University, and Veterans General Hospital-Taipei, Taiwan, ROC.
Correspondence to Shih-Ann Chen, MD, Division of Cardiology, Veterans General Hospital-Taipei, Taiwan. E-mail sachen{at}vghtpe.gov.tw
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Abstract |
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Background—Atrial fibrillation (AF) can be initiated by ectopic beats originating from the atrial or great venous tissues. This study investigated the anatomic characteristics and electrophysiological properties of pulmonary veins (PVs), as well as the possible mechanisms and response to drugs of ectopic foci, and assessed the effects of radiofrequency (RF) ablation on AF initiated by ectopic beats originating from PVs.
Methods and Results—Seventy-nine patients with frequent episodes of paroxysmal AF and 10 control patients were included. Distal PVs showed the shortest effective refractory periods (ERPs), and right superior PVs showed a higher incidence of intra-PV conduction block than left superior PVs. Superior and left PVs had longer myocardial sleeves than inferior and right PVs, respectively. These electrophysiological characteristics were similar between AF and control patients. Propranolol, verapamil, and procainamide suppressed ectopic beats that originated from the PVs. Of 116 ectopic foci that initiated AF, 103 (88.8%) originated from PVs. A mean of 7±3 RF applications completely eliminated 110 ectopic foci (94.8%). During the 6±2-month follow-up period, 68 patients (86.1%) were free of AF without any antiarrhythmic drugs. Follow-up transesophageal echocardiogram showed 42.4% of ablated PVs had focal stenosis. One patient had mild exertional dyspnea after ablation, but it resolved 3 months later; 1 patient had onset of mild exertional dyspnea 5 months after ablation.
Conclusions—Electrophysiological characteristics of PVs are different from those in the atria. Ectopic beats from PVs can initiate AF, and ß-adrenergic receptor blocker, calcium channel blockers, and sodium channel blockers can suppress these ectopic beats. Careful mapping and elimination of these ectopic foci can cure paroxysmal AF.
Key Words: ablation • fibrillation • veins • electrophysiology
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Introduction |
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Atrial fibrillation (AF) can be initiated by ectopic beats from the cristal terminalis, ostium of the coronary sinus, interatrial septum, atrial free wall, and pulmonary veins (PVs).1 2 3 4 5 The mechanism of AF initiated by ectopic beats from PVs is not clear; furthermore, the effects of antiarrhythmic drugs on these ectopic beats have not been reported.1 2 3 4 5 6 7 8 9 10
Haissaguerre et al and this laboratory have demonstrated that radiofrequency (RF) catheter ablation can effectively eliminate AF initiated by ectopic beats from a focal area.1 2 3 4 5 However, the possible side effects, such as RF energy–induced PV stenosis, have not been studied in detail.
This study investigated the anatomic characteristics and electrophysiological properties of PVs, as well as possible mechanisms and the response to drugs of ectopic foci, and assessed the effects of RF ablation on AF initiated by ectopic beats originating from PVs.
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Methods |
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Group I consisted of 79 patients with frequent, daily attacks of paroxysmal AF (PAF). Group II consisted of 10 patients with a concealed left-side free-wall accessory pathway (without AF); these patients underwent the study protocol of PV electrophysiology after successful ablation of accessory pathways. None of the group II patients had other cardiovascular diseases. As described previously, all antiarrhythmic drugs except amiodarone were discontinued for
5 half-lives before the study.4 5 11 12
Catheter Positions
As described previously, 3 multipolar electrode catheters
(Mansfield or Daig Co) were placed in the anterolateral right atrium
(RA), the His bundle area, and the coronary sinus. A 7F,
20-pole, deflectable halo catheter (Cordis-Webster Co) was positioned
around the tricuspid annulus to simultaneously record
RA activation in the lateral wall and the low RA isthmus; the cristal
terminalis and superior vena cava were also mapped if RA ectopic foci
were suspected.4 5 11 12
The atrial transseptal procedure and techniques of PV angiography have been described previously.4 5 In brief, 2 6F, deflectable, decapolar catheters (2-mm interelectrode distance and 5-mm space between each electrode pair; Daig Co) were put into the PVs guided by PV venography. Intravenous heparin was administered in a dose of 2000 to 3000 U at half-hour to 1-hour intervals if needed to maintain activated clotting time >300 seconds.
Study of Electropharmacological Characteristics
A programmed digital stimulator (DTU- 215, Bloom Associates Ltd)
was used to deliver electrical impulses of 2.0-ms duration at twice the
diastolic threshold. Intracardiac bipolar electrograms were
displayed simultaneously with ECG leads
V1, I, II, or aVF on a multichannel recorder
(Prucka Engineering, Inc). Activation times were measured where the
first rapid deflection of the local electrogram crossed the
baseline.
Effective Refractory Period
Nineteen patients completed this study protocol. An extrastimuli
technique (2-ms increment) during 3 different pacing cycle lengths
(700, 500, and 300 ms) was used to measure the effective refractory
period (ERP) at 16 sites (Table
). Measurement of ERP in the
proximal and distal right superior PV (RSPV) and left superior PV
(LSPV) was repeated after administration of isoproterenol (2
µg/min).
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Spontaneous Onset of Atrial Premature Contraction/AF
As described previously,4 an algorithm was used to
facilitate initiation of spontaneous atrial premature contractions
(APCs) or AF (Figure 1).
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Effects of Propranolol, Verapamil, and
Procainamide on Spontaneous APC/AF
The density of APCs and burst AF (number of APCs and episodes of
burst AF within 5 minutes) was measured during baseline or after
isoproterenol infusion. Thirty patients were further randomized to
receive propranolol (0.02 mg/kg of body weight for the
loading dose over 10 minutes and 0.04 mg ·
kg-1 · h-1 for
maintenance), verapamil (0.15 mg/kg of body weight
for the loading dose over 10 minutes and 0.3 mg ·
kg-1 · h-1 for
maintenance), or procainamide (15 mg/kg of body weight
for the loading dose at a rate of 50 mg/min and 4 mg/min for
maintenance). Spontaneous APCs and AF were assessed 10 minutes
after the loading dose was given.
Radiofrequency Ablation
As described previously,4 5 the presumed ablation
site showed the earliest bipolar activity and/or a local unipolar QS
pattern of ectopic beats preceding AF from PVs. The ablation catheter
(4-mm-tip electrode, Mansfield, Boston Scientific) was connected with
an EPT-1000 generator (EP Technology) delivering a 550-kHz sine wave
output between the distal electrode of the ablation catheter and the
cutaneous patch electrode placed over the left scapula. A
temperature-control model with a maximal temperature setting of 60°C
was used. Each application of RF energy was delivered for 20 to 40
seconds. If patients had cough, burning pain, or severe bradycardia, RF
energy was stopped, and a maximal temperature setting of 50°C to
55°C was used. The protocols used to induce spontaneous initiation of
AF before ablation were repeated to assess the effects of RF ablation
at 30 minutes after the last pulse. Procedural success was defined as
the absence of ectopic beats and inability to reinitiate AF with the
same protocols used before ablation. Heparin (1000 U/h) was
continuously administered for 24 hours, and oral coumadin was continued
for 2 months with an international normalized ratio (INR) level between
2.0 and 3.0.
Follow-Up
Close clinical follow-up (2 weeks, 1 month, and then every 2
months), 24-hour Holter monitoring, cardiac event recorder, and
transthoracic echocardiography (within
3 days and 1 to 6 months after ablation) were obtained in the patients
at this institution. Serial follow-up transesophageal
echocardiograms were performed in 48 patients within 3 days and 1 to 6
months after ablation to evaluate stenosis of PVs. If patients
experienced palpitation, another 24-hour Holter monitoring or cardiac
event recorder was used to evaluate their condition.
Statistical Analysis
Parametric data are presented as mean±SD.
Paired t test was used to analyze changes in
parametric data before and after an intervention in the same
group. Nonparametric data were analyzed by the
2 test with Yates correction or Fisher exact
test. ANOVA was used for comparison of ERPs at different sites. The
effects of antiarrhythmic drugs on the incidence of APCs and AF were
analyzed with the sign test. A P value <0.05 was
considered significant.
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Results |
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Clinical Characteristics
All 79 patients had frequent attacks of clinically documented PAF on 24-hour Holter recordings (6±4 episodes/d; duration 28±30 min/d; 4±4 episodes/d with symptoms and 2±3 episodes/d without patient events; mean, median, and range of APC number were 892±311, 863, and 267 to 3256, respectively). These episodes of PAF were refractory to or intolerant of 3±1 antiarrhythmic drugs. Thirty-nine patients (50%) had other associated diseases (Table 1
).
Electrophysiological Characteristics
Effective Refractory Periods
In patients with AF, the longest and shortest ERPs were at the
Bachmann bundle and distal RSPV, respectively. ERPs at proximal sites
of the RSPV and LSPV were significantly longer than those at the distal
sites. After isoproterenol infusion, ERP at the distal RSPV was shorter
than at the proximal RSPV, but ERP at the distal LSPV was similar to
that at the proximal LSPV. The mean slopes of ERP against pacing cycle
length were significantly lower at the low lateral RA than at other
sites. Comparisons between patients with AF and control subjects did
not show any difference in ERPs and slopes of ERP (Table 2 and Figure 2).
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Local PV Electrograms
PV potentials (with a sharp upstroke, narrow duration <50 ms, and
an amplitude >0.05 mV) were preceded by far-field atrial potential
with a slow slope (depolarization rate dV/dt <0.5 mV/s).3
The length of the myocardial sleeve showing PV potentials calculated
from the number of bipolar recordings was significantly less in
the right side and inferior PVs than those in the left side
and superior PVs, respectively. Control subjects showed similar
characteristics of PV potentials (Figures 3 and 4).
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Ectopic Beats With Initiation of AF
Seventy-three patients (92%) had spontaneous initiation of
sustained (>30 seconds) AF during baseline observation or after
different maneuvers. Six patients (7.6%) had only burst ectopic beats
without initiation of sustained AF (Figure 1). During ectopic
beats from PVs, PV potentials preceded atrial potentials. During the
initial 5 seconds of spontaneous depolarization of ectopic foci, 27
patients (34.2%) showed conduction block; 19 ectopic foci were in the
RSPV (Figure 5).
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Electropharmacological Characteristics
Sixteen patients had spontaneous APCs or burst AF during the
baseline study. After propranolol (n=5),
verapamil (n=5), or procainamide (n=6) infusion,
the density of PV ectopic beats and episodes of burst AF decreased
significantly. Fourteen patients had spontaneous APCs or burst AF after
isoproterenol infusion. After pretreatment with propranolol
(n=5), verapamil (n=5), or procainamide (n= 4),
isoproterenol infusion could not induce any episode of sustained AF;
the density of APCs and density of burst AF were significantly
decreased (Figures 6 and 7).
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RF Ablation
Results
Table 3 and Figure 8 show the 116 ectopic foci that
initiated spontaneous AF. Forty-four patients had 1, 33 patients had 2,
and 2 patients had 3 ectopic foci. Among the 103 ectopic foci from PVs,
40 (38.8%) were in the ostium and proximal PV (<20 mm inside the
PV), and 63 (61.2%) were in the distal PV (20 to 40 mm inside the
PV). Bipolar electrograms in the successful ablation sites were 84±31
ms (range 40 to 150 ms) before the ectopic P wave. After 7±3 (range 2
to 13) applications of RF energy (mean 25±12 W), 97 of 103 ectopic
foci from PVs were completely eliminated; the other 6 ectopic foci were
partially eliminated (APCs were still present, but spontaneous AF
could not be initiated). The mean procedure time required for mapping
and ablation was 90±32 minutes, and fluoroscopic time was 42±20
minutes.
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Complications and Follow-Up
Two patients had transient cerebral ischemic attack within
24 hours after ablation; fortunately, they recovered well. One patient
had hemothorax and hemopericardium immediately after successful
ablation; after pericardiocentesis and pleural tapping, the patient
recovered well.
Forty-two patients underwent follow-up transthoracic echocardiogram, and 2 had pericardial effusion (5 mm in width) without any symptoms on the second day; it resolved spontaneously at 1 month follow-up. An iatrogenic small atrial septal defect with trivial shunt (width of shunt 2.6±1.0 mm) was found in 43 of 45 patients within 3 days; in each case, it had closed spontaneously 3 months later. Injury of valvular function or thrombus was not found. Twenty-five (42.4%) of 59 PV foci showed peak PV flow velocity >80 cm/s obtained from transesophageal echocardiogram within 3 days after ablation (65±7 versus 125±10 cm/s; P<0.01); these 25 foci also showed an increase in peak PV flow velocity (120±12 cm/s), with a mean pressure gradient of 4.9±2.3 mm Hg at 3-month follow-up. Three patients had a double stenosis: 1 patient was completely asymptomatic; 1 had mild exertional dyspnea after RF ablation, which resolved 3 months later; and the remaining patient had onset of mild exertional dyspnea 5 months after RF ablation, with 12 and 18 mm Hg pressure gradients within the RSPV and LSPV, respectively. Among 7 patients who underwent repeated ablation, PV angiography did not reveal any stenotic lesion or pressure gradient within the PV or between the PV and left atrium.
During the follow-up period (mean 6±2 months, range 2 to 13 months), 11 patients (13.9%) had early recurrence of AF within 72 hours after ablation. In all 11 patients, AF was converted to sinus rhythm after 24-hour intravenous administration of amiodarone (1200 mg). Four of the 11 patients had late (1±1 month) recurrence of AF, and they underwent a repeated ablation with success. Among the other 68 patients without early recurrence, 4 had late recurrence of AF (1±1 month); 3 of these 4 patients underwent a repeated ablation with success, and the other patient underwent AV junction ablation with implantation of a permanent pacemaker. In the 7 patients who received repeated ablation of ectopic foci, 5 foci were from the original sites and 2 were from the left atrial posterior wall. In total, 68 patients (86.1%) were free of symptomatic AF without any antiarrhythmic drug, and 10 (12.7%) were free of symptomatic AF with 1 type of antiarrhythmic drug (which failed to control AF before ablation) during the follow-up period. Late follow-up 24-hour Holter monitoring was obtained in 49 patients and showed a significant decrease in ectopic beats compared with baseline (892±311 versus 210±66 beats/d; P<0.01); symptomatic and sustained AF was not found, and nonsustained (asymptomatic) AF was found in 12 patients (3±1 episode/d, duration 8±3 s/episode).
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Discussion |
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Cardiac Muscle in the PVs
This study found longer myocardial sleeves with PV potentials in the superior than in the inferior PVs and confirmed the previous anatomic and pathological findings that superior PVs had longer and better-developed myocardial sleeves than inferior PVs.13 These results might explain the fact that most of the ectopic foci that initiate AF were from the superior PVs, because myocardial sleeves in the inferior PVs were shorter and less developed.
Electrophysiology of Atria and PVs
Regional Difference of ERPs
Previous human studies included no systemic study of atrial ERP in
different sites; thus, the results were
controversial.14 15 16 17 18 The present study first showed
similar atrial ERP distribution patterns between AF patients and
control subjects; furthermore, the longest and shortest ERPs were in
the Bachmann bundle area and the distal PVs, respectively. In the
pericarditis and atrial rapid pacing models of AF,19 20
the anatomic distribution of atrial ERP is also similar to
that observed in normal dogs.
Maladaptation of ERP
Maladaptation of atrial ERP has been considered to be related to
AF.21 The present study found that the rate adaptation
response was different between the low RA and other areas in both the
control group and patients with AF. We also demonstrated the site
difference of maladaptation and its correlation with reinitiation of
AF.22 23 These findings suggest the site difference of
atrial electrophysiology. However, maladaptation of PV ERP was not
found in any patient.
ERP at Proximal and Distal Portions of PVs
This study showed longer ERPs in the proximal than the distal PV,
and this finding might be similar to Cheung's report24
that action potential duration was longer in the proximal PV than in
the distal PV. Longer ERPs in proximal than in distal PVs could block
the impulses originating from the distal PV and reduce the possibility
of AF. However, the differences in ERP between proximal and distal PVs
were decreased after isoproterenol infusion; this finding possibly
suggests that isoproterenol can attenuate the protection mechanism of
the proximal PV, and fast, spontaneous activation from the distal PV
could be conducted to the proximal PV and left atrium and initiate AF,
in the same way that burst pacing of atrial tissue can induce
AF.
Conduction Block Within the PV
This study demonstrated that 34.2% of patients had intra-PV
conduction block, and 70.4% of these cases had conduction block in the
RSPV. Haissaguerre et al3 demonstrated concealed
discharges and speculated that decremental conduction properties
existed in PVs. A more complex arrangement of the myocardial
sleeve with more anisotropic conduction properties in the RSPV than in
the LSPV and a significant difference in ERP between the proximal and
distal RSPV might be possible mechanisms. The other possible mechanism
is impedance mismatch.25 Because the proximal PV has a
relatively larger mass than the distal PV, impulses from distal PVs
would be blocked in the proximal PVs or blocked in the PV/atrial
junction.
Spontaneous Activity Originating From PVs
This laboratory4 5 showed that spontaneous activity
from the atria or PVs can initiate AF. Previous
studies24 26 demonstrated that ouabain infusion or
norepinephrine infusion could trigger the onset of rapid
repetitive activity from the distal PV. Jais et al2
first described the focal source AF of in humans and found that most
spontaneous AF originated from PVs.
The present study found that a ß-receptor blocker, a calcium channel blocker, and procainamide could suppress spontaneous ectopic beats and AF from PVs. This laboratory has demonstrated11 that ß-receptor blockers and calcium channel blockers can effectively terminate or prevent induction of focal-type atrial tachycardia, including atrial tachycardias originating from PV ostia, and that the mechanism of this type of atrial tachycardia is abnormal automaticity or triggered activity. Furthermore, our previous study23 proved that procainamide could prevent secondary AF caused by accumulation of intracellular calcium after rapid atrial pacing. Because the ß-receptor blocker and procainamide were less effective in suppressing triggered activity, the mechanism of the ectopic beats that initiate AF might be abnormal automaticity.28 29
RF Ablation of AF Initiated by Ectopic Beats
The present study showed a higher success rate and a lower
recurrence rate than that by Haissaguerre et al.3
It is difficult to define which type of APCs should be ablated to
prevent initiation of AF; in the present study, a single-beat APC
that did not induce a burst of rapid, repetitive atrial beats or
initiation of AF was not chosen for RF ablation.4 5 Some
patients with drug-refractory AF can be treated with original
antiarrhythmic drugs after catheter ablation of PV foci; thus, hybrid
therapy may be an alternative choice for management of AF. The true
incidence of recurrent AF after initially successful ablation is
unknown because attacks of AF were paroxysmal in these patients, and
the methods used to evaluate and follow up were not
perfect.4 5 We also found that all recurrences
occurred within the first 2 months after ablation.
The potential risk of cardiac perforation during transseptal catheterization and catheter ablation should be considered. Extensive linear ablation of atrial tissue and PVs includes the risk of PV stenosis, cardiac tamponade, cerebral emboli, or death.30 Focal ablation around or inside the PV may be a relatively safe procedure. Although 42.4% of patients showed an increase in PV flow velocity, a larger number of patients and a longer follow-up period are necessary to prove safety and efficacy.
Study Limitations
The first limitation of this study is that there is no uniform
definition of focal AF. Further confirmation of the continuous or
intermittent firing of PV activity during AF would be helpful to define
the term focal AF. In this study, AF was initiated by ectopic beats
originating from a single or multiple foci in the PVs. Second, this
study only included 3 patients who also had RA ectopic foci; thus, the
results cannot be extrapolated to all AF. Third, we used a bipolar
pacing technique to measure ERP; unipolar pacing may be a better
technique in small tissue.
Conclusions
The electrophysiological
characteristics of PVs are different from those in the atria. Ectopic
beats from PVs can initiate AF, and ß-adrenergic receptor blockers
and calcium and sodium channel blockers can suppress these ectopic
beats. Careful mapping and elimination of these ectopic foci can cure
PAF.
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Acknowledgments |
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This study was supported in part by grants from the National Scientific Council and Veterans General Hospital/Yang-Ming University (NSC 88-2314-B-010-094 and VGHYM87-S4-24, S3-17; VGH-47, 301).
Received March 30, 1999; revision received June 22, 1999; accepted July 9, 1999.
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Y.-J. Lin, C.-T. Tai, T. Kao, S.-L. Chang, L.-W. Lo, T.-C. Tuan, A. R. Udyavar, W. Wongcharoen, Y.-F. Hu, H.-W. Tso, et al. Spatiotemporal Organization of the Left Atrial Substrate After Circumferential Pulmonary Vein Isolation of Atrial Fibrillation Circ Arrhythmia Electrophysiol, June 1, 2009; 2(3): 233 - 241. [Abstract] [Full Text] [PDF]
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H. Sohara, H. Takeda, H. Ueno, T. Oda, and S. Satake Feasibility of the Radiofrequency Hot Balloon Catheter for Isolation of the Posterior Left Atrium and Pulmonary Veins for the Treatment of Atrial Fibrillation Circ Arrhythmia Electrophysiol, June 1, 2009; 2(3): 225 - 232. [Abstract] [Full Text] [PDF]
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T. Yamada, Y. Murakami, T. Okada, H. T. McElderry, H. Doppalapudi, A. E. Epstein, V. J. Plumb, T. Murohara, and G. N. Kay Electroanatomic mapping in the catheter ablation of premature atrial contractions with a non-pulmonary vein origin Europace, November 1, 2008; 10(11): 1320 - 1324. [Abstract] [Full Text] [PDF]
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E. Buch and K. Shivkumar Exploring the potential of pulmonary vein recordings: can they help elucidate mechanisms of paroxysmal atrial fibrillation? Europace, June 1, 2008; 10(6): 690 - 691. [Full Text] [PDF]
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J. Chen, M. K. Off, E. Solheim, P. Schuster, P. I. Hoff, and O.-J. Ohm Treatment of atrial fibrillation by silencing electrical activity in the posterior inter-pulmonary-vein atrium Europace, March 1, 2008; 10(3): 265 - 272. [Abstract] [Full Text] [PDF]
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H. Oral Post-operative atrial fibrillation and oxidative stress: a novel causal mechanism or another biochemical epiphenomenon? J. Am. Coll. Cardiol., January 1, 2008; 51(1): 75 - 76. [Full Text] [PDF]
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K. A. Hafid, H. C. Xin, W. Xi, Z. Q. Yan, and Y. Bo Difference between electrical remodelling after pulmonary veins and right atrium appendage pacing Europace, July 13, 2007; (2007) eum108v1. [Abstract] [Full Text] [PDF]
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J. M. Stulak, J. A. Dearani, T. M. Sundt III, R. C. Daly, C. G.A. McGregor, K. J. Zehr, and H. V. Schaff Superiority of cut-and-sew technique for the Cox maze procedure: Comparison with radiofrequency ablation J. Thorac. Cardiovasc. Surg., April 1, 2007; 133(4): 1022 - 1027. [Abstract] [Full Text] [PDF]
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M. Hirose and K. R. Laurita Calcium-mediated triggered activity is an underlying cellular mechanism of ectopy originating from the pulmonary vein in dogs Am J Physiol Heart Circ Physiol, April 1, 2007; 292(4): H1861 - H1867. [Abstract] [Full Text] [PDF]
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J.-Y. Kuo and S.-A. Chen Is Vagal Denervation a Good Alternative or Just Adjunctive to Pulmonary Vein Isolation in Catheter Ablation of Atrial Fibrillation? J. Am. Coll. Cardiol., March 27, 2007; 49(12): 1349 - 1351. [Full Text] [PDF]
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H. L. Estner, I. Deisenhofer, A. Luik, G. Ndrepepa, C. von Bary, B. Zrenner, and C. Schmitt Electrical isolation of pulmonary veins in patients with atrial fibrillation: reduction of fluoroscopy exposure and procedure duration by the use of a non-fluoroscopic navigation system (NavX(R)) Europace, August 1, 2006; 8(8): 583 - 587. [Abstract] [Full Text] [PDF]
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T. Neumann, A. Erdogan, T. Dill, H. Greiss, A. Berkowitsch, J. Sperzel, M. Kuniss, K. Kurzidim, C. W. Hamm, and H.-F. Pitschner Asymptomatic recurrences of atrial fibrillation after pulmonary vein isolation Europace, July 1, 2006; 8(7): 495 - 498. [Abstract] [Full Text] [PDF]
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M. Haissaguerre, M. Hocini, P. Sanders, Y. Takahashi, M. Rotter, F. Sacher, T. Rostock, L.-F. Hsu, A. Jonsson, M. D. O'Neill, et al. Localized Sources Maintaining Atrial Fibrillation Organized by Prior Ablation Circulation, February 7, 2006; 113(5): 616 - 625. [Abstract] [Full Text] [PDF]
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M. Hocini, P. Jais, P. Sanders, Y. Takahashi, M. Rotter, T. Rostock, L.-F. Hsu, F. Sacher, S. Reuter, J. Clementy, et al. Techniques, Evaluation, and Consequences of Linear Block at the Left Atrial Roof in Paroxysmal Atrial Fibrillation: A Prospective Randomized Study Circulation, December 13, 2005; 112(24): 3688 - 3696. [Abstract] [Full Text] [PDF]
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J. Sra, D. Krum, A. Malloy, M. Vass, B. Belanger, E. Soubelet, R. Vaillant, and M. Akhtar Registration of Three-Dimensional Left Atrial Computed Tomographic Images With Projection Images Obtained Using Fluoroscopy Circulation, December 13, 2005; 112(24): 3763 - 3768. [Abstract] [Full Text] [PDF]
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W. P. Beukema, A. Elvan, H. T. Sie, A. R. Ramdat Misier, and H. J.J. Wellens Successful Radiofrequency Ablation in Patients With Previous Atrial Fibrillation Results in a Significant Decrease in Left Atrial Size Circulation, October 4, 2005; 112(14): 2089 - 2095. [Abstract] [Full Text] [PDF]
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H.-M. Tsao, M.-H. Wu, S. Higa, K.-T. Lee, C.-T. Tai, N.-W. Hsu, C.-Y. Chang, and S.-A. Chen Anatomic Relationship of the Esophagus and Left Atrium: Implication for Catheter Ablation of Atrial Fibrillation Chest, October 1, 2005; 128(4): 2581 - 2587. [Abstract] [Full Text] [PDF]
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S.-H. Lee, C.-T. Tai, M.-H. Hsieh, H.-M. Tsao, Y.-J. Lin, S.-L. Chang, J.-L. Huang, K.-T. Lee, Y.-J. Chen, J.-J. Cheng, et al. Predictors of Non-Pulmonary Vein Ectopic Beats Initiating Paroxysmal Atrial Fibrillation: Implication for Catheter Ablation J. Am. Coll. Cardiol., September 20, 2005; 46(6): 1054 - 1059. [Abstract] [Full Text] [PDF]
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Y.-J. Lin, C.-T. Tai, T. Kao, H.-W. Tso, J.-L. Huang, S. Higa, Y. Yuniadi, B.-H. Huang, T.-Y. Liu, P.-C. Lee, et al. Electrophysiological Characteristics and Catheter Ablation in Patients With Paroxysmal Right Atrial Fibrillation Circulation, September 20, 2005; 112(12): 1692 - 1700. [Abstract] [Full Text] [PDF]
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J. Edelson, R. Shah, and D. Ost A 45-Year-Old Man With Left Lung Hypoperfusion and Possible Pulmonary Embolism Chest, August 1, 2005; 128(2): 1032 - 1036. [Full Text] [PDF]
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T. Arentz, R. Weber, N. Jander, G. Burkle, J. von Rosenthal, T. Blum, J. Stockinger, L. Haegeli, F. J. Neumann, and D. Kalusche Pulmonary haemodynamics at rest and during exercise in patients with significant pulmonary vein stenosis after radiofrequency catheter ablation for drug resistant atrial fibrillation Eur. Heart J., July 2, 2005; 26(14): 1410 - 1414. [Abstract] [Full Text] [PDF]
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H. Purerfellner Pulmonary vein stenosis: still the Achilles heel of ablation for atrial fibrillation? Eur. Heart J., July 2, 2005; 26(14): 1355 - 1357. [Full Text] [PDF]
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M. Hocini, P. Sanders, P. Jais, L.-F. Hsu, R. Weerasoriya, C. Scavee, Y. Takahashi, M. Rotter, F. Raybaud, L. Macle, et al. Prevalence of pulmonary vein disconnection after anatomical ablation for atrial fibrillation: consequences of wide atrial encircling of the pulmonary veins Eur. Heart J., April 1, 2005; 26(7): 696 - 704. [Abstract] [Full Text] [PDF]
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C. C. Lang, V. Santinelli, G. Augello, A. Ferro, F. Gugliotta, S. Gulletta, G. Vicedomini, C. Mesas, G. Paglino, S. Sala, et al. Transcatheter radiofrequency ablation of atrial fibrillation in patients with mitral valve prostheses and enlarged atria: Safety, feasibility, and efficacy J. Am. Coll. Cardiol., March 15, 2005; 45(6): 868 - 872. [Abstract] [Full Text] [PDF]
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R. Cappato, H. Calkins, S.-A. Chen, W. Davies, Y. Iesaka, J. Kalman, Y.-H. Kim, G. Klein, D. Packer, and A. Skanes Worldwide Survey on the Methods, Efficacy, and Safety of Catheter Ablation for Human Atrial Fibrillation Circulation, March 8, 2005; 111(9): 1100 - 1105. [Abstract] [Full Text] [PDF]
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M. M. Scheinman and E. Keung The year in clinical electrophysiology J. Am. Coll. Cardiol., March 1, 2005; 45(5): 790 - 795. [Full Text] [PDF]
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T.-J. Cha, J. R. Ehrlich, L. Zhang, D. Chartier, T. K. Leung, and S. Nattel Atrial Tachycardia Remodeling of Pulmonary Vein Cardiomyocytes: Comparison With Left Atrium and Potential Relation to Arrhythmogenesis Circulation, February 15, 2005; 111(6): 728 - 735. [Abstract] [Full Text] [PDF]
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D. L. Packer, P. Keelan, T. M. Munger, J. F. Breen, S. Asirvatham, L. A. Peterson, K. H. Monahan, M. F. Hauser, K. Chandrasekaran, L. J. Sinak, et al. Clinical Presentation, Investigation, and Management of Pulmonary Vein Stenosis Complicating Ablation for Atrial Fibrillation Circulation, February 8, 2005; 111(5): 546 - 554. [Abstract] [Full Text] [PDF]
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F. Gaita, R. Riccardi, D. Caponi, D. Shah, L. Garberoglio, L. Vivalda, A. Dulio, A. Chiecchio, E. Manasse, and R. Gallotti Linear Cryoablation of the Left Atrium Versus Pulmonary Vein Cryoisolation in Patients With Permanent Atrial Fibrillation and Valvular Heart Disease: Correlation of Electroanatomic Mapping and Long-Term Clinical Results Circulation, January 18, 2005; 111(2): 136 - 142. [Abstract] [Full Text] [PDF]
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P. D. Bella, S. Riva, G. Fassini, M. Casella, C. Carbucicchio, N. Trevisi, M. Berti, F. Giraldi, and G. Maccabelli Long-term follow-up after radiofrequency catheter ablation of atrial fibrillation: Role of the acute procedure outcome and of the clinical presentation Europace, January 1, 2005; 7(2): 95 - 103. [Abstract] [Full Text] [PDF]
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A. W. Bowman and S. J. Kovacs Prediction and assessment of the time-varying effective pulmonary vein area via cardiac MRI and Doppler echocardiography Am J Physiol Heart Circ Physiol, January 1, 2005; 288(1): H280 - H286. [Abstract] [Full Text] [PDF]
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P. Melnyk, J. R. Ehrlich, M. Pourrier, L. Villeneuve, T.-J. Cha, and S. Nattel Comparison of ion channel distribution and expression in cardiomyocytes of canine pulmonary veins versus left atrium Cardiovasc Res, January 1, 2005; 65(1): 104 - 116. [Abstract] [Full Text] [PDF]
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R. Khan Identifying and understanding the role of pulmonary vein activity in atrial fibrillation Cardiovasc Res, December 1, 2004; 64(3): 387 - 394. [Abstract] [Full Text] [PDF]
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L. Lickfett, M. Mahesh, C. Vasamreddy, D. Bradley, V. Jayam, Z. Eldadah, T. Dickfeld, D. Kearney, D. Dalal, B. Luderitz, et al. Radiation Exposure During Catheter Ablation of Atrial Fibrillation Circulation, November 9, 2004; 110(19): 3003 - 3010. [Abstract] [Full Text] [PDF]
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N. A. Mokadam, P. M. McCarthy, A. M. Gillinov, W. H. Ryan, M. R. Moon, M. J. Mack, S. L. Gaynor, S. M. Prasad, S. A. Wickline, M. S. Bailey, et al. A Prospective Multicenter Trial of Bipolar Radiofrequency Ablation for Atrial Fibrillation: Early Results Ann. Thorac. Surg., November 1, 2004; 78(5): 1665 - 1670. [Abstract] [Full Text] [PDF]
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F. Ouyang, D. Bansch, S. Ernst, A. Schaumann, H. Hachiya, M. Chen, J. Chun, P. Falk, A. Khanedani, M. Antz, et al. Complete Isolation of Left Atrium Surrounding the Pulmonary Veins: New Insights From the Double-Lasso Technique in Paroxysmal Atrial Fibrillation Circulation, October 12, 2004; 110(15): 2090 - 2096. [Abstract] [Full Text] [PDF]
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H. J.J. Wellens Cardiac arrhythmias: The quest for a cure: A historical perspective J. Am. Coll. Cardiol., September 15, 2004; 44(6): 1155 - 1163. [Abstract] [Full Text] [PDF]
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I. Kholova and J. Kautzner Morphology of Atrial Myocardial Extensions Into Human Caval Veins: A Postmortem Study in Patients With and Without Atrial Fibrillation Circulation, August 3, 2004; 110(5): 483 - 488. [Abstract] [Full Text] [PDF]
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A. Kluge, T. Dill, O. Ekinci, J. Hansel, C. Hamm, H. F. Pitschner, and G. Bachmann Decreased Pulmonary Perfusion in Pulmonary Vein Stenosis After Radiofrequency Ablation: Assessment With Dynamic Magnetic Resonance Perfusion Imaging Chest, August 1, 2004; 126(2): 428 - 437. [Abstract] [Full Text] [PDF]
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