Arrhythmogenic Triggers of Atrial Fibrillation Arising From the Common Trunk of the Inferior Pulmonary Veins.

A 48-year-old man underwent catheter ablation for symptomatic paroxysmal atrial fibrillation (AF). Computed tomography revealed an anatomic anomaly of the pulmonary veins (PVs): conjoined left and right inferior PVs (CIPV) ().

Figure.

Activation map (A) and intracardiac electrograms (B) for the AF triggering beat (yellow arrow in A,B). (C) Ablation lesion set for CIPV and superior PVs. AF, atrial fibrillation; CIPV, conjoined left and right inferior PVs; PV, pulmonary vein.

During the procedure, short episodes of spontaneous AF repetitively occurred from the same trigger, so we performed activation mapping and identified the earliest activation during the AF trigger at the common trunk of the CIPV ().

CIPV is a rare PV variant that is reported in 0.9–1.5% of patients who underwent AF ablation., Yamane et al reported that no ectopies were observed in the CIPV, whereas 57% of ectopic triggers were inside the CIPV in the study by Yu et al. However, detailed mapping of the ectopic trigger from the CIPV was not performed in Yu’s study, and the arrhythmogenicity of the common trunk of the CIPV is unknown. Thus, the best ablation strategy for CIPV remains inconclusive (i.e., individual PV isolation or en-bloc CIPV isolation). Our case showed that the common trunk of the CIPV has potential as an AF trigger. En-bloc CIPV ablation was performed to fully cover the arrhythmogenic AF foci (). The superior PVs were individually isolated. During a 14-month follow-up period, no atrial tachyarrhythmia recurred. The en-bloc isolation line would be an optimal ablation lesion set for CIPV, although further studies are needed to establish a therapeutic strategy for CIPV ablation.

Disclosures

None.