Superior vena cava (SVC) obstruction is associated with the gradual development of venous collaterals. We present a rare form of systemic-to-pulmonary subpleural collateral pathway that developed in the bridging subpleural pulmonary veins in a 54-year-old woman with complete SVC obstruction. This uncommon collateral pathway represents a rare form of acquired right-to-left shunt due to previous pleural adhesions with an increased risk of stroke due to right-to-left venous shunting, which requires lifelong anticoagulation.
*Collateral Circulation/physiology ; Female ; Humans ; Middle Aged ; Multidetector Computed Tomography ; Phlebography/methods ; Pulmonary Veins/physiopathology/*radiography ; Stroke/complications ; Superior Vena Cava Syndrome/physiopathology/*radiography ; Veins/physiopathology

OBJECTIVEThe development status of pulmonary artery is one of the most important criteria for decision-making strategy and predicting postoperative outcome in congenital heart disease with decreased pulmonary blood flow. Currently, Nakata index and McGoon index have been used as morphologic index in evaluating the development status of pulmonary artery. Those indices have some shortcoming. It was recently found that pulmonary veins index is a more precise morphological indicator of pulmonary blood flow and development status of pulmonary vessels. This study aimed to explore an index of evaluating pulmonary blood stream and the development of pulmonary vessels, as a criterion for surgical decision-making strategy.

METHODSThe diameters of left and right pulmonary arteries and pulmonary veins were measured on DSA films in 74 patients with congenital heart disease with decreased pulmonary blood flow, The correlative analysis was done between Nakata index, McGoon index, pulmonary vein index (PVI) and postoperative outcome which were the length of stay in ICU, duration of mechanical ventilation and dose of inotropic drugs.

RESULTSExcellent correlations between the size of pulmonary veins and pulmonary arteries were found, the correlation between left pulmonary veins and distal portion of left pulmonary artery was 0.73, between left pulmonary veins and proximal portion of left pulmonary artery was 0.72, right pulmonary veins and distal portion of right pulmonary artery was 0.67, and right pulmonary veins and proximal portion of right pulmonary artery was 0.71. The length of stay in ICU, duration of mechanical ventilation and dose of inotropic drugs correlated well with PVI (r = -0.51, -0.478, and -0.693). Compared with Nakata index and McGoon index, PVI was a better criterion for evaluating the developmental status of the whole pulmonary vessels. In the right ventricular outlet reconstruction patients, the McGoon index for patients with low cardiac output syndrome (LCOS) was 1.36 +/- 0.51, and 1.97 +/- 0.58 for patients without LCOS (t = 2.347, P < 0.05), the Nakata index for patients with LCOS was 164 +/- 106 mm(2)/m(2) and 269 +/- 124 mm(2)/m(2) for patients without LCOS (t = 2.218, P < 0.05), the PVI for patients with LCOS was 152 +/- 77 mm(2)/m(2) and 273 +/- 125 mm(2)/m(2) for patients without LCOS (t = 2.936, P < 0.01), pulmonary vessel index of patients with LCOS was less than that of those without LCOS. When PVI was < or = 180 mm(2)/m(2), postoperative hemodynamics was unstable, the frequency of low cardiac output syndrome and mortality significantly increased.

CONCLUSIONSThe development of pulmonary arteries and pulmonary veins correlated with each other. PVI is a precise morphological indicator of pulmonary blood flow and development of pulmonary vessels. It is a helpful indicator to decide surgical strategy.

Adolescent ; Child ; Child, Preschool ; Female ; Heart Defects, Congenital ; physiopathology ; Hemodynamics ; Humans ; Infant ; Male ; Pulmonary Artery ; growth & development ; physiopathology ; Pulmonary Veins ; growth & development ; physiopathology

BACKGROUNDMajor atrial coronary arteries, including the sinus node artery (SNA), were commonly found in the areas involved in atrial fibrillation (AF) ablation and could cause difficulties in achieving linear block at the left atrial (LA) roof. The SNA is a major atrial coronary artery of the atrial coronary circulation. This study aimed to determine impact of the origin of SNA on recurrence of AF after pulmonary vein isolation (PVI) in patients with paroxysmal AF.

METHODSSeventy-eight patients underwent coronary angiography for suspected coronary heart disease, followed by catheter ablation for paroxysmal AF. According to the origin of SNA from angiographic findings, they were divided into right SNA group (SNA originating from the right coronary artery) and left SNA group (SNA originating from the left circumflex artery). Guided by an electroanatomic mapping system, circumferential pulmonary vein ablation (CPVA) was performed in both groups and PVI was the procedural endpoint. All patients were followed up at 1, 3, 6, 9 and 12 months post-ablation. Recurrence was defined as any episode of atrial tachyarrhythmias (ATAs), including AF, atrial flutter or atrial tachycardia, that lasted longer than 30 seconds after a blanking period of 3 months.

RESULTSThe SNA originated from the right coronary artery in 34 patients (43.6%) and the left circumflex artery in 44 patients (56.4%). Freedom from AF and antiarrhythmic drugs (AADs) at 1 year was 67.9% (53/78) for all patients. After 1 year follow-up, 79.4% (27/34) in right SNA group and 59.1% (26/44) in left SNA group (P = 0.042) were in sinus rhythm. On multivariate analysis, left atrium size (HR = 1.451, 95%CI: 1.240 - 1.697, P < 0.001) and a left SNA (HR = 6.22, 95%CI: 2.01 - 19.25, P = 0.002) were the independent predictors of AF recurrence.

CONCLUSIONSThe left SNA is more frequent in the patients with paroxysmal AF. After one year follow-up, the presence of a left SNA was identified as an independent predictor of AF recurrence after CPVA in paroxysmal AF.

Aged ; Atrial Fibrillation ; physiopathology ; surgery ; Catheter Ablation ; Coronary Vessels ; physiopathology ; Female ; Humans ; Male ; Middle Aged ; Pulmonary Veins ; surgery ; Recurrence

Inter atrial block (IAB) is a prevailing cardiac conduction abnormality that is under-recognized in clinical practice. IAB has strong association with atrial arrhythmia, left atrial enlargement, and electromechanical discordance, increasing the risk of atrial fibrillation (AF) and myocardial ischemia. IAB was generally believed to be caused by impaired conduction along the Bachmann bundle (BB). However, there are three other conduction pathways, including the fibers posteriorly in the vicinity of the right pulmonary veins (VRPV), transseptal fibers in the fossa ovalis (FO), and muscular bundles on the inferior atrial surface near the coronary sinus (CS). We hypothesized that the importance of BB on IAB might have been overestimated. To test this hypothesis, various combinations of conduction pathway blocks were simulated based on a realistic human atrial model to investigate their effects on the index of clinical diagnosis standard of IAB using a simulated 12-lead electrocardiogram (ECG). Firstly, the results showed that the BB block alone could not generate typical P wave morphology of IAB, and that the combination of BB and VRPV pathway block played important roles in the occurrence of IAB. Secondly, although single FO and CS pathways play subordinate roles in inter atrial conduction, their combination with BB and VRPV block could also produce severe IAB. In summary, this simulation study has demonstrated that the combinations of different inter atrial conduction pathways, rather than BB alone, resulted in ECG morphology of IAB. Attention needs to be paid to this in future pathophysiological and clinical studies of IAB.
Adult ; Arrhythmias, Cardiac/physiopathology* ; Atrial Fibrillation/physiopathology* ; Computer Simulation ; Coronary Sinus/physiopathology* ; Electrocardiography ; Heart ; Heart Atria ; Humans ; Male ; Models, Anatomic ; Models, Cardiovascular ; Pulmonary Veins/physiopathology*

BACKGROUNDCircumferential pulmonary vein isolation (CPVI), as the basal ablation strategy for treating atrial fibrillation (AF), not only isolates the connection between the left atrium (LA) and the pulmonary veins (PVs), but also induces extensive atrial endocardia damage. This could have an effect on the sinus pulse conduction in the LA and subsequently result in changes of P-wave characteristics of surface electrocardiogram (ECG).

METHODSFifty consecutive patients underwent CPVI for symptomatic drug-refractory paroxysmal AF. The 12-lead ECGs were recorded one day before CPVI and seven days after CPVI at sinus rhythm by a standard resting ECG device. Measured characteristics of the P-wave consisted of P-wave duration (PWD), P-wave amplitude (PWA), P-wave polarity (PWP), P-wave notch, P-wave dispersion and P-wave index.

RESULTSAfter CPVI, a prevalent decrease of PWD, PWA, and P-wave dispersion was observed; a transition of P-wave polarity was observed in the leads of III, aVL and aVF. The rate of P-wave notch decreased significantly in all leads, especially in the leads of II, III, aVF and V3. Patients with sinus rhythm had a shorter P-wave dispersion and P-wave index and had a lower rate of P-wave notch compared with the patients with recurrent atrial tachyarrhythmia.

CONCLUSIONObservations from using the surface ECG showed that CPVI has instant effects on the electrical conduction in the LA, and several changes of P-wave characteristics associated with development of AF are improved by CPVI.

Aged ; Atrial Fibrillation ; physiopathology ; surgery ; Catheter Ablation ; methods ; Electrocardiography ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Pulmonary Veins ; surgery

We present a case of pulmonary vein (PV) stenosis after radio-frequency (RF) ablation, in which a hemodynamic change in the pulmonary artery was similar to that of congenital PV atresia on time-resolved contrast-enhanced magnetic resonance angiography (TR-MRA). A 48-year-old man underwent RF ablation due to atrial fibrillation. The patient subsequently complained of hemoptysis, dyspnea on exertion, and right chest pain. Right PV stenosis after catheter ablation was diagnosed through chest computed tomography and lung perfusion scan. Pulmonary TR-MRA revealed the pulmonary artery via systemic arterial collaterals and draining systemic collateral veins. On a velocity-encoded cine image, the flow direction of the right pulmonary artery was reversed in the diastolic phase and the left pulmonary artery demonstrated continuous forward flow throughout the cardiac cycle. These hemodynamic changes were similar to those seen in congenital unilateral PV atresia.
Atrial Fibrillation/*surgery ; Blood Flow Velocity ; Catheter Ablation/*adverse effects ; Constriction, Pathologic/*etiology/pathology ; Contrast Media ; Humans ; *Magnetic Resonance Angiography ; Male ; Middle Aged ; Pulmonary Artery/pathology/physiopathology ; *Pulmonary Circulation ; Pulmonary Veins/*pathology/physiopathology

OBJECTIVETo investigate the influence of persistent rapid atrial pacing on the levels of connexin 43 (Cx43) and type III collagen in pulmonary vein and atrium in a canine model.

METHODSSixteen mongrel dogs were divided into rapid atrial pacing (RAP) group (n = 8) and normal control group (n = 8) randomly. In the RAP group, atrial pacing was performed with a rate of 400 bpm for 10 weeks to establish atrial fibrillation model. The tissues of left superior pulmonary vein (LSPV), left atrial free wall (LAFW) and right atrial appendage (RAA) were collected from each dogs. The levels of Cx43 and type III collagen were measured in each tissue.

RESULTSTen weeks later, persistent atrial fibrillation was induced in all dogs in RAP group. The level of Cx43 in RAP group was higher than that in normal control group (LSPV: 3370.91 +/- 275.11 vs 1405.82 +/- 90.38, P < 0.05; LAFW: 2448.68 +/- 272.10 vs 1467.12 +/- 147.93, P < 0.05, RAA: 2331.96 +/- 199.61 vs 1288.27 +/- 216.22, P < 0.05). The level of Cx43 in LSPV was higher than that in LAFW and RAA in RAP group, whereas the difference between LAFW and RAA was not significant in RAP group. The quantities of type III collagen in RAP group were higher than those in normal control group (LSPV: 3301.97 +/- 309.70 vs 1404.56 +/- 178.02, P < 0.05; LAFW: 2477.86 +/- 190.43 vs 1479.20 +/- 187.17, P < 0.05; RAA: 2045.92 +/- 139.43 vs 1417.07 +/- 139.43, P < 0.05). The quantities of type III collagen in LSPV was higher than those in LAFW and RAA in RAP group.

CONCLUSIONSPersistent rapid atrial pacing could increase the levels of Cx43 and type III collagen in pulmonary vein and atrium in a canine model of atrial fibrillation. The levels of Cx43 and type III collagen in pulmonary vein were higher than those in atrium. This findings indicated that pulmonary vein may be a crucial regions in maintaining atrial fibrillation.

Animals ; Atrial Fibrillation ; metabolism ; physiopathology ; Cardiac Pacing, Artificial ; methods ; Collagen Type III ; blood ; Connexin 43 ; blood ; Disease Models, Animal ; Dogs ; Female ; Male ; Pulmonary Veins ; metabolism ; physiopathology

BACKGROUNDPulmonary vein (PV) isolation has been developed to treat patients with atrial fibrillation (AF), and the electrophysiological endpoint of PV isolation is the disappearance or dissociation of pulmonary vein potentials (PVPs). Pulmonary vein tachycardia (PVT) is the dissociated PV rhythm with a rapid rate. However, the characteristics and significance of PVT after pulmonary vein isolation in patients with AF remains unclear.

METHODSFrom June 2003 to June 2005, a total of 285 consecutive patients with drug refractory AF were included in this study, and they underwent segmental pulmonary vein ablation (SPVA) or circumferential pulmonary vein ablation (CPVA). PV isolation was the initial endpoint for both approaches with documenting disappearance or dissociation of PVPs. PVT was characterized as dissociated activities within PVs with a circle length (CL) of < 300 ms, and was classified into organized PVT or disorganized PVT according to the variance of CL. Systematic follow-up was conducted after initial procedures. Continuous variables were analyzed by Student's t test and categorical variables were analyzed by chi-square test.

RESULTSThree hundred and fifteen PVs were ablated in 85 patients underwent SPVA approach, 400 circular lesions surrounding ipsilateral PVs (including 790 PVs) were produced in the rest of 200 patients received CPVA approach. Electrical isolation was achieved in all of these PVs. Of these, PVPs were abolished in 89.8% (992/1105) of the ablated PVs, dissociated PV rhythms were documented in the rest 10.2 % (113/1105) of the treated PVs. Among the 113 dissociated PV rhythms, 28 met the criteria of PVT with mean CL of (155 +/- 43) ms (2 PVTs in 2 patients received SPVA, 26 PVTs in 18 patients underwent CPVA). PVT was more frequently documented in patients underwent CPVA approach [9.0% (18/200) vs 2.3% (2/85), P = 0.04]. During the 6-month follow-up, it was indicated that no significant difference existed in AF free rate between patients with PVT and those without PVT (P = 0.75).

CONCLUSIONSPVT dissociated from LA activations can be documented after PV isolation, especially in patients underwent CPVA approach. However, PVT does not affect the follow-up results.

Adolescent ; Adult ; Aged ; Atrial Fibrillation ; physiopathology ; surgery ; Catheter Ablation ; adverse effects ; Female ; Humans ; Male ; Middle Aged ; Pulmonary Veins ; physiopathology ; surgery ; Tachycardia ; etiology

OBJECTIVETo report the electrophysiological findings and the ablation strategies in patients with atrial tachyarrhythmias (ATAs) or atrial fibrillation (AF) recurrence after left atrial circumferential ablation (LACA) in the treatment of AF.

METHODS91 patients with AF had LACA procedure from April 2004 to May 2006, 19 of which accepted the second ablation procedure due to ATAs or AF recurrence. In all the 19 patients [17 male, 2 female, age 25 - 65 (53 +/- 12) years], 11 presented with paroxysmal AF before the first ablation procedure, 2 with persistent AF and 6 with permanent AF. Pulmonary vein potentials (PVP) were investigated in both sides in all the patients.

RESULTSDelayed PVP was identified inside the left circular line in 5 patients, in the right in 1 and both in 2 during sinus rhythm. "Gap" conduction was found and successfully closed guided by circular mapping catheter. In 3 cases, irregular left atrial tachycardia was caused by fibrillation rhythm inside the left ring via decremental "gap" conduction. Reisolation was done successfully again guided by 3-D mapping and made the left atrium in sinus rhythm but the fibrillation rhythm was still inside the left ring. Pulmonary vein tachycardia with 1:1 conduction to the left atrium presented in one case and reisolation stopped the tachycardia. No PVP was discovered in both sides in 4 patients but other tachycardias could be induced, including two right atrial scar related tachycardias, two supraventricular tachycardias mediated by concealed accessory pathway, one cavo-tricuspid isthmus dependent atrial flutter and one focal atrial tachycardia near the coronary sinus ostium. All the tachycardias in these 4 patients were successfully ablated with the help of routine and 3-D mapping techniques. In the rest 3, which were in AF rhythm, LACA was successfully done again. After a mean follow-up of 4 - 26 (11.5 +/- 8.5) months, 16 patients were symptom free without anti-arrhythmic drug therapy; 1 of them had frequent palpitation attack with Holter recording of atrial premature contractions; 2 of them with permanent AF became paroxysmal in one, and still in AF in the other.

CONCLUSIONSReconduction between the left atrium and the pulmonary veins is the dominant factor for post-LACA ATAs and AF recurrence. Other forms of atrial tachycardias or supraventricular tachycardias may coexist with AF or sometimes trigger AF. LACA can not sufficiently modify AF substrate in some permanent AF patients.

Adult ; Aged ; Atrial Fibrillation ; physiopathology ; therapy ; Cardiac Electrophysiology ; Catheter Ablation ; methods ; Female ; Follow-Up Studies ; Heart Atria ; Humans ; Male ; Middle Aged ; Pulmonary Veins ; Tachycardia ; physiopathology ; therapy

BACKGROUNDLinear ablation of left atrium (LA) guided by three dimensional (3-D) electroanatomical mapping (Carto) has been used in many centres worldwide for the treatment of atrial fibrillation (AF) instead of pure anatomical approaches. There were little data about linear ablation of LA guided by Carto and double Lasso catheters in China. We report the results of linear ablation of LA guided by both Carto and double Lasso catheters.

METHODSAfter the anatomical model of LA and all pulmonary veins (PVs) had been established, circumferential ablations of the left pulmonary vein antrum and the right pulmonary vein antrum were performed with 2 circumferential mapping catheters (Lasso) placed within the ipsilateral superior and inferior PVs. The endpoint of ablation was abolishment or dissociation of the pulmonary vein potentials (PVPs). Oral amiodarone or propafenone was taken for at least 3 months by patients with persistent AF, permanent AF or those whose PVPs had not been isolated completely. The recurrence of atrial tachyarrhythmias was observed 3 months after the procedure.

RESULTSThere were 106 patients (mean age, 51.4 +/- 9.9 years). Seventy-eight patients had paroxysmal AF, 12 persistent AF and 16 permanent AF. Onset of atrial fibrillation occurred in 52 patients during ablation procedure. Thirty-two patients restored to sinus rhythm eventually after the procedure. Abolishment or dissociation of PVPs was accomplished during the procedure in 94 patients (88.7%). The duration of procedure and exposure to X-ray were (213 +/- 45) minutes and (32.5 +/- 12.8) minutes, respectively. Among the 87 patients followed up for over 3 months, 62 were free of atrial tachyarrhythmias (including 8 patients who were still taking oral amiodarone). The success rate was 71.3% in the first procedure. Two patients had pericardial effusion treated by pericardial puncture and effusion drainage. No pulmonary vein stenosis, atrioesophageal fistula, stroke or procedural death occurred.

CONCLUSIONSCombination of double Lasso catheters with 3-D electroanatomical mapping to guide the linear ablation of left atrium procedure can confirm the isolation of PVPs.

Adult ; Aged ; Atrial Fibrillation ; physiopathology ; surgery ; Catheter Ablation ; methods ; Electrophysiologic Techniques, Cardiac ; methods ; Female ; Heart Atria ; surgery ; Humans ; Male ; Middle Aged ; Pulmonary Veins ; physiopathology