High-density epicardial mapping of the pulmonary vein-left atrial junction in humans: Insights into mechanisms of pulmonary vein arrhythmogenesis

Geoffrey Lee, Steven J Spence, Andrew Teh, John Goldblatt, Marco Larobina, Victoria Atkinson, Robin Brown, Joseph B. Morton, Prashanthan Sanders, Peter M Kistler, Jonathan M. Kalman

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20 Citations (Scopus)


Background: The pulmonary veins (PVs) and the PVLA (left atrium) junction are established sources of triggers initiating atrial fibrillation. In addition, they have been implicated in the maintenance of arrhythmia. Objective: To undertake high-density electrophysiological characterization of the right superior PVLA junction in humans. Methods: Mapping was performed in 18 patients without a history of atrial fibrillation undergoing cardiac surgery. A high-density epicardial plaque was positioned at the anterior right superior pulmonary vein covering 3 regions: LA, PVLA junction, and the PV. Isochronal maps were created during (1) sinus rhythm (SR); (2) LA pacing (LA-Pace); (3) PV pacing (PV-Pace); (4) LA programmed electrical stimulation (LA-PES); and (5) PV programmed electrical stimulation (PV-PES). Regional differences in conduction slowing/conduction block (CS/CB) and the prevalence of fractionated signals (FS) and double potentials (DPs) were assessed. Results: A region of isochronal crowding representing CS/CB developed at the PVLA junction in 84% of the maps. Three distinct activation patterns were seen. Pattern 1: Uniform SR activation without CS/CB. LA-Pace and PES caused 1 to 2 lines of isochronal crowding (CS/CB) at the PVLA junction. Pattern 2: CS/CB occurred at the PVLA junction in SR. LA/PV-Pace and LA/PV-PES caused an increase in CS/CB at the PVLA junction with widely split DPs and FS. Pattern 3: A single incomplete line of CS at the PVLA junction in SR. With LA/PV pacing and LA/PV-PES, multiple lines (<3) of CS/CB developed at the PVLA junction with evidence of circuitous activation and a marked increase in DPs and FS. Conclusion: High-density epicardial mapping of the right superior pulmonary vein demonstrates marked functional conduction delay and circuitous activation patterns at the PVLA junction, creating the substrate for reentry.

Original languageEnglish
Pages (from-to)258-264
Number of pages7
JournalHeart Rhythm
Issue number2
Publication statusPublished - Feb 2012
Externally publishedYes


  • Atrial fibrillation
  • Epicardial mapping
  • Pulmonary vein electrophysiology

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