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How to do circular mapping catheter-guided pulmonary vein antrum isolation: The Cleveland Clinic approach

      Atrial fibrillation (AF) is one of the 20th-century epidemics. Over the past 2 decades, significant advances have been made in the treatment of AF, the last being percutaneous ablation. Haissaguerre et al
      • Haissaguerre M.
      • Jais P.
      • Shah D.C.
      • Takahashi A.
      • Hocini M.
      • Quiniou G.
      • Garrigue S.
      • Le Mouroux A.
      • Le Metayer P.
      • Clementy J.
      Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins.
      showed that AF triggers often originate from the thoracic veins. The goal of present-day AF ablation is to electrically “disconnect” the pulmonary veins (PVs) from the rest of the left atrium (LA) by ablating around the origin of the veins.
      • Haissaguerre M.
      • Shah D.C.
      • Jais P.
      • Hocini M.
      • Yamane T.
      • Deisenhofer I.
      • Garrigue S.
      • Clementy J.
      Mapping-guided ablation of pulmonary veins to cure atrial fibrillation.
      At present, at least two techniques are used for AF ablation. The first is an anatomic approach guided by nonfluoroscopic navigation systems (e.g., CARTO (Biosense Webster, Diamond Bar, CA), NavX (St Jude Medical, St Paul, MN), LocaLisa (Medtronic, Minneapolis, MN)), in which radiofrequency (RF) ablations are delivered circumferentially outside the PV ostia with a variety of additional ablation lesions without necessarily demonstrating complete electrical isolation.
      • Cappato R.
      • Calkins H.
      • Chen S.A.
      • Davies W.
      • Iesaka Y.
      • Kalman J.
      • Kim Y.H.
      • Klein G.
      • Packer D.
      • Skanes A.
      Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation.
      • Pappone C.
      • Rosanio S.
      • Oreto G.
      • Tocchi M.
      • Gugliotta F.
      • Vicedomini G.
      • Salvati A.
      • Dicandia C.
      • Mazzone P.
      • Santinelli V.
      • Gulletta S.
      • Chierchia S.
      Circumferential radiofrequency ablation of pulmonary vein ostia a new anatomic approach for curing atrial fibrillation.
      The second approach, which is performed at the Cleveland Clinic, requires electrical isolation of the entire PV antra as the endpoint. This is achieved by a circular mapping technique with the use of intracardiac echocardiography for guidance (Figure 1).
      Figure thumbnail gr1
      Figure 1Anatomic definition of pulmonary vein ostium and antrum using three-dimensional computed tomographic imaging (A) and intracardiac echocardiography (B). Note that the right and left pulmonary vein antra include the posterior wall of the left atrium. LSPV = left superior pulmonary vein; RSPV = right superior pulmonary vein.
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