New Directions in Intracardiac Echocardiography

Introduction: Pulmonary vein (PV) isolation (PVI) has been recently proposed as an effective technique to cure atrial fibrillation (AF).Aims of the Study: The aim of this study was to investigate the efficacy of a novel technique utilizing a computerized three-dimensional mapping system (QMS2^TM) with a multielectrode basket catheter (MBC) for PVI and to reveal the relation between the style of breakthrough and the network of the PV musculature.Methods: Sixty-five consecutive patients with frequent AF attacks underwent PV mapping with a 31-mm MBC, and a three-dimensional color animation of the potential map was constructed by the QMS2^TM. The animation color schema was arranged to minimize the low-amplitude left atrial (LA) potentials and emphasize the high-amplitude PV potentials (PVPs). The longitudinal PVP map enabled us to recognize the true breakthroughs and reveal the network of the PV musculature.Results: A total of 205 PVs (65 left superior PVs, 65 right superior PVs, 57 left inferior PVs and 18 right inferior PVs) were mapped and successful PVI was achieved in all PVs, except one that had no PVPs, with a mean radiofrequency duration of 7 ± 5 minutes per PV. In about 90% of the PVs, a final radiofrequency application eliminated all the distal PVPs simultaneously because the PVI was performed at the appropriate LA-PV junction. A single segmental breakthrough was detected in 17 PVs, single broad breakthrough in 83 PVs, multiple separate breakthroughs with a distal connection between the PV musculatures extending from each separate breakthrough in 88 PVs and multiple separate breakthroughs without that connection in 16 PVs. During the follow-up period, fifty-one (78%) patients were free of symptomatic AF without any antiarrhythmic drugs after multiple procedures (thirty-three (51%) of those patients after the first procedure) and no PV stenosis was found.Conclusions: Computerized three-dimensional potential mapping can be useful for PVI because it can not only identify the true breakthrough, but can also confirm the elimination of the breakthroughs by the change in the activation sequence through the network of the PV musculature.There was no financial support for this study.