In the first procedure, we performed PV isolation, SVC isolation, and
CTI ablation. However, AF persisted and immediately recurred soon after
electric cardioversion. Therefore we performed GP ablation around PVs
(posterior Left GP, anterior right GP, and superior left GP) and linear
ablation between the superior PVs (i.e., roofline). The ATP challenge
was performed during ongoing AF and not repeated after the restoration
of sinus rhythm. In the second procedure, we performed re-isolation of
the reconnected right PV and
SVC.
Isoproterenol infusion induced frequent PACs from multiple foci (white
arrows in the left and middle panel). ATP injection induced AF from
multiple foci (white arrows in the right panel) without dormant
conduction of the isolated veins. We identified the trigger foci in the
distal portion of CS and the left PV and LA appendage ridge.
Radiofrequency ablation along the ligament of Marshall and lateral
aspect of the mitral annulus (opposed to the distal CS) suppressed these
PACs.
A bolus administration of ATP still induced AF. The first beat
initiating AF was documented at the CS ostium and RA septum (white
arrows).
C . Therefore, we performed HFS within the CS and RA septum.
Vagal responses by HFS were observed at three sites in the RA septum
adjacent to the interatrial groove and two sites near the CS ostium
(blue tags in the right panels). Following the RF ablation at these
sites, AF was no longer inducible by ATP provocation.
TA = tricuspid annulus. Other abbreviations are the same as Figure 1 and
2.