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(Circulation. 2000;102:937.)
© 2000 American Heart Association, Inc.

Images in Cardiovascular Medicine

Transition From Atrioventricular Node Reentry Tachycardia to Atrial Fibrillation Begins in the Pulmonary Veins

Eugen C. Palma, MD; Kevin J. Ferrick, MD; Jay N. Gross, MD; Soo G. Kim, MD; John D. Fisher, MD

From the Arrhythmia Service of the Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY.

Correspondence to Eugen C. Palma, MD, Albert Einstein College of Medicine, Montefiore Medical Center, Arrhythmia Service, 111 East 210th St, Bronx, NY 10467. E-mail eupalma{at}montefiore.org

A37-year-old man with frequent episodes of paroxysmal atrial fibrillation refractory to antiarrhythmic therapy (and no other documented arrhythmias on multiple Holter examinations) underwent an attempt at radiofrequency ablation of the atrial fibrillation. Catheter positions are shown in the left anterior oblique view in Figure 1 and include 2 catheters in the left and right upper pulmonary veins. During mapping, the patient developed atrioventricular node reentry tachycardia (AVNRT) both spontaneously and with atrial extrastimuli; this AVNRT was later ablated. Before ablation, the patient’s rhythm spontaneously changed from AVNRT to atrial fibrillation (Figure 2). The catheter in the right upper pulmonary vein clearly recorded pulmonary venous potentials, which initiated atrial ectopic beats (as seen in the change of the activation sequence in the coronary sinus) and subsequent atrial fibrillation.

View larger version (116K): [in this window] [in a new window]   Figure 1. Left anterior oblique projection shows the position of the catheters in the right atrium (RA), coronary sinus (CS), right upper pulmonary vein (RUPV), and left upper pulmonary vein (LUPV). The catheter in the right atrium was later advanced into the right ventricle.

View larger version (43K): [in this window] [in a new window]   Figure 2. Transition from AVNRT to atrial fibrillation began in the pulmonary veins. RUPV indicates right upper pulmonary vein; LUPV, left upper pulmonary vein; P, proximal; D, distal; CS, coronary sinus; 1, most proximal; 5, most distal; and RV, right ventricle. Leads are shown from top to bottom on the left. The left side of the tracing shows AVNRT conducted with a right bundle branch block aberrancy, whereas the right side shows atrial fibrillation. Where the transition occurs, an asterisk marks a premature right upper pulmonary venous beat that does not capture the left atrium, as demonstrated by the unchanged proximal to distal activation sequence of the coronary sinus. The next pulmonary venous premature beat (short arrow) captures the left atrium (the coronary sinus is now activated distal to proximal [long arrow]) and initiates atrial fibrillation.

Atrial fibrillation is a common occurrence in patients with supraventricular tachycardias, including AVNRT, and often starts during the supraventricular tachycardia.¹ The mechanism by which atrial fibrillation begins during supraventricular tachycardias is unknown, although spontaneous atrial premature depolarizations have been cited as a trigger.² Furthermore, the mechanism behind why atrial fibrillation recurs after successful ablation of supraventricular tachycardia is unknown.³ As seen in this patient, 1 site from which spontaneous ectopy can initiate atrial fibrillation during AVNRT is in the pulmonary veins; this is similar to what has been reported during sinus rhythm.⁴ This provides a potential mechanism for the continued incidence of atrial fibrillation after successful ablation of AVNRT and perhaps other supraventricular tachycardias as well.

References

1. Hurwitz JL, German LD, Packer DL, et al. Occurrence of atrial fibrillation in patients with paroxysmal supraventricular tachycardia due to atrioventricular nodal reentry. Pacing Clin Electrophysiol. 1990;13:705–710.[Medline] [Order article via Infotrieve]
   
2. Sung RJ, Castellanos A, Mallon SM, et al. Mechanisms of spontaneous alternation between reciprocating tachycardia and atrial flutter-fibrillation in the Wolff-Parkinson-White syndrome. Circulation. 1977;56:409–416.[Free Full Text]
   
3. Weiss R, Knight BP, Bahu M, et al. Long-term follow-up after radiofrequency ablation of paroxysmal supraventricular tachycardia in patients with tachycardia-induced atrial fibrillation. Am J Cardiol. 1997;80:1609–1610.[Medline] [Order article via Infotrieve]
   
4. Haissaguerre M, Jais P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339:659–666.[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Palma, E. C. Articles by Fisher, J. D. Search for Related Content PubMed PubMed Citation Articles by Palma, E. C. Articles by Fisher, J. D. Related Collections Electrophysiology Arrhythmias, clinical electrophysiology, drugs Ablation/ICD/surgery