Baldinger et al.; Pulmonary Vein Unexcitability during Isolation Procedures
Supplemental Methods
Periprocedural management
Antiarrhythmic drugs were discontinued ≥5 half-lives prior to ablation, except
for amiodarone. All patients received oral anticoagulants for at least 1 month
prior to the procedure. Transesophageal echocardiography, when deemed
appropriate, was performed within 5 days of the procedure. Vitamin K
antagonists were continued uninterrupted; the last dose of novel
anticoagulants was given the day before the procedure and resumed the night
of the procedure.
Mapping and ablation
As previously described.1 PVI was performed under general anesthesia and
heparin was administered to maintain an activated clotting time of >350
seconds. Intracardiac ultrasound (Cartosound, Biosense-Webster, Diamond
Bar, CA, USA) was used for visualizing transseptal punctures and improving
catheter contact. A duodecapolar catheter (LiveWire, St Jude Medical, St.
Paul, MN, USA) was looped into the coronary sinus (CS) and onto the lateral
wall of the right atrium (RA). Deflectable (Agilis, St Jude Medical) and fixedcurve (SR0, St Jude Medical) transseptal vascular sheaths were inserted into
the LA using separate transseptal punctures. Using the CARTO 3 (Biosense
Webster), electroanatomical mapping system (EAMS) a detailed fast
anatomical map was generated for LA anatomy by using a multipolar,
multispline diagnostic catheter (Pentaray NAV, Biosense-Webster). A threedimensional model of the LA was used as a reference in 26 of 30 patients, by
using the “CARTO-Merge” feature. Electroanatomic points were acquired in
all regions of the LA and within PVs. Bipolar voltage was considered abnormal
when it measured less than 0.5mV.2 Depth of circumferential normal voltage
within the PV-sleeves at baseline was measured using the measuring tool in
the EAMS software. Ablation and pacing were performed using a 3.5-mm-tip
catheter (ThermoCool SF or ThermoCool SmartTouch, Biosense Webster).
RF energy was delivered using a generator (Stockert GmbH, Freiburg,
Germany) in a power-controlled mode at 20–30W at an irrigation rate of 17–
30mL/min with the goal of achieving a catheter tip temperature of <45°C.
Goals for individual lesions included average contact force >10 grams (25/30
cases) and impedance decrease of 10Ω or greater, except when any
esophageal heating occurred as judged by an esophageal temperature probe
(Vital-Temp, Vital Signs Inc, Engelwood, CO, USA) at the level of the ablation
catheter tip. Additional endpoints of the procedure were electrical isolation of
all PVs by antral ablation without carinal lesions, anatomical completion of the
RFA-line with less than 5mm gaps between the center of lesion markers,
electrical unexcitability of the RFA-line3 and lack of dormant conduction
following 12mg of intravenous adenosine.4 Additional ablation at sites of
complex fractionated electrograms and application of LA lines was at the
discretion of the operator.
1.
2.
3.
4.
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Supplemental Figure
Supplemental Figure: Theoretical contributions of PV unexcitability to
entrance- and exit block
A) Both PV sleeves show entrance block and capture with exit block due to a
complete antral RFA-line. B) Both PVs show entrance block and capture with
exit block despite an incomplete RFA-line. C) one or D) both PV-sleeves
unexcitable with incomplete antral RFA-line.
+ : excitable to pacing; - : unexcitable to pacing