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      Detection of Epicardial Connection Through Intercaval Bundle Involving Right Pulmonary Veins After Ipsilateral Circumferential Ablation by Intra‐Atrial Activation Sequence Pacing From the Right Pulmonary Vein

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          Abstract

          Background

          An epicardial connection (EC) through the intercaval bundle (EC‐ICB) between the right pulmonary vein (RPV) and right atrium (RA) is one of the reasons for the need for carina ablation for PV isolation and may reduce the acute and chronic success of PV isolation. We evaluated the intra‐atrial activation sequence during RPV pacing after failure of ipsilateral RPV isolation and sought to identify specific conduction patterns in the presence of EC‐ICB.

          Methods and Results

          This study included 223 consecutive patients who underwent initial catheter ablation of atrial fibrillation. If the RPV was not isolated using circumferential ablation or reconnected during the waiting period, an exit map was created during mid‐RPV carina pacing. If the earliest site on the exit map was the RA, the patient was classified into the EC‐ICB group. The exit map, intra‐atrial activation sequence, and RPV‐high RA time were evaluated. First‐pass isolation of the RPV was not achieved in 36 patients (16.1%), and 22 patients (9.9%) showed reconnection. Twelve and 28 patients were classified into the EC‐ICB and non‐EC‐ICB groups, respectively, after excluding those with multiple ablation lesion sets or incomplete mapping. The intra‐atrial activation sequence showed different patterns between the 2 groups. The RPV‐high RA time was significantly shorter in the EC‐ICB than in the non‐EC‐ICB group (69.2±15.2 versus 148.6±51.2 ms; P<0.001), and RPV‐high RA time<89.0 ms was highly predictive of the existence of an EC‐ICB (sensitivity, 91.7%; specificity, 89.3%).

          Conclusions

          An EC‐ICB can be effectively detected by intra‐atrial sequencing during RPV pacing, and an RPV‐high RA time of <89.0 ms was highly predictive.

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          Most cited references23

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          OUP accepted manuscript

          (2020)
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            Epicardial connection between the right-sided pulmonary venous carina and the right atrium in patients with atrial fibrillation: A possible mechanism for preclusion of pulmonary vein isolation without carina ablation

            Ablation of the pulmonary venous carina is occasionally required for pulmonary vein isolation (PVI) despite its nonessential role in ipsilateral PVI from the anatomical (endocardial) viewpoint. Although the Bachmann bundle (BB) is a common and main interatrial band, local variations in small tongues of muscular fibers were frequently found in autopsy studies.
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              Atrial structure and fibres: morphologic bases of atrial conduction.

              The relationship between anatomy and function has long been recognised. Understanding the gross structure, and the myoarchitecture, of the atriums is fundamental to investigations into the substrates and therapy of atrial fibrillation. Based primarily on our experience with normal human hearts, this review provides, firstly, a basis of comparison of gross structures as seen in the clinical situation, and in animals commonly used in experimental studies. Secondly, we discuss the general arrangement of myocardial fibres with respect to gross topography in the normal human heart. The right atrium is dominated by an extensive array of pectinate muscles within the extensive appendage, whereas the left atrium is relatively smooth-walled, with a much smaller tubular appendage. Myoarchitecture displays parallel alignment of fibres along distinct muscle bundles, such as the terminal crest and Bachmann's bundle. Within the smooth wall of the left atrium, there is a marked transmural change in the orientation of the muscular fibres. Abrupt changes in orientation, and mixed arrangements, are common between bundles. Other than Bachmann's bundle, the muscular bridges which provide interatrial connections, and connections between the left atrium and the coronary sinus and inferior caval vein, are highly variable. Inhomogeneities both in gross structure and myoarchitecture are common in the normal heart. These should be taken into account when investigating hearts from patients known to have had a history of arrhythmias, in devising computer models, or when refining diagnostic and therapeutic strategies.
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                Author and article information

                Contributors
                takeshikato@me.com
                Journal
                J Am Heart Assoc
                J Am Heart Assoc
                10.1002/(ISSN)2047-9980
                JAH3
                ahaoa
                Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
                John Wiley and Sons Inc. (Hoboken )
                2047-9980
                19 April 2024
                07 May 2024
                : 13
                : 9 ( doiID: 10.1002/jah3.v13.9 )
                : e034004
                Affiliations
                [ 1 ] Department of Cardiology Toyama Prefectural Central Hospital Toyama Japan
                [ 2 ] Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Science Kanazawa Japan
                [ 3 ] Department of Pediatrics Toyama Prefectural Central Hospital Toyama Japan
                [ 4 ] Department of Diagnostic Radiology Toyama Prefectural Central Hospital Toyama Japan
                Author notes
                [*] [* ] Correspondence to: Takeshi Kato, Department of Cardiology, Kanazawa University Graduate School of Medical Sciences, 13‐1 Takara‐machi, Kanazawa 920‐8641, Japan. Email: takeshikato@ 123456me.com

                Author information
                https://orcid.org/0000-0001-7871-9494
                https://orcid.org/0000-0003-4108-5525
                https://orcid.org/0009-0005-6146-0582
                https://orcid.org/0000-0001-5465-3515
                https://orcid.org/0000-0001-6599-629X
                https://orcid.org/0009-0005-1732-6052
                https://orcid.org/0009-0002-7022-9364
                https://orcid.org/0000-0001-5703-0399
                https://orcid.org/0000-0003-0836-1196
                https://orcid.org/0000-0002-1540-4417
                Article
                JAH39567 JAHA/2023/034004
                10.1161/JAHA.123.034004
                11179885
                38639381
                79bc7ef5-18f6-405c-8eca-07ca162c5dac
                © 2024 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                : 14 December 2023
                : 20 March 2024
                Page count
                Figures: 7, Tables: 2, Pages: 10, Words: 5045
                Categories
                Original Research
                Original Research
                Arrhythmia and Electrophysiology
                Custom metadata
                2.0
                07 May 2024
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.4.2 mode:remove_FC converted:13.05.2024

                Cardiovascular Medicine
                atrial activation sequence,intercaval epicardial connection,right pulmonary vein,atrial fibrillation,electrophysiology

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