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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@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 . . . [Full Text of this Article]

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