EP IMAGES:FROM CELL TO BEDSIDE Section Editor: David S. Rosenbaum, M.D. Adenosine Triphosphate Enhanced Contrast Pulmonary Venogram to Facilitate Pulmonary Vein Ablation HUNG-FAT TSE, M.D., KATHY L.F. LEE, M.B., and CHU-PAK LAU, M.D. From the Cardiology Division, Department of Medicine, and the Institute of Cardiovascular Science and Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong Recent studies have demonstrated that pulmonary vein (PV) ablation is a promising treatment for patients with par- oxysmal atrial brillation. 1-4 During either focal 1-4 or circum- ferential 5,6 PV ablation procedure, contrast pulmonary venog- raphy is essential to delineate the anatomy of the PVs to guide positioning of the mapping and ablation catheters and to assess the development of PV stenosis after the procedure. However, selective pulmonary venography that requires multiple cannu- lation and contrast injection in the PVs is time consuming and may be difcult. Adenosine has been used in pediatric cathe- terization laboratories for better visualization of venous anat- omy. We describe a modied technique to perform nonselec- tive contrast pulmonary venogram enhanced by adenosine triphosphate (ATP) injection, which can facilitate the PV ab- lation procedure. A 45-year-old man with paroxysmal atrial brillation underwent focal PV ablation. After standard trans- septal puncture, nonselective contrast pulmonary venograms were obtained by injection of 20 mL of contrast via an 8-French sheath positioned in the mid-portion of left atrium. Before ATP injection, only the ostia and the proximal segment of the left superior and left inferior PVs could be clearly visualized during venography (Fig. left; LIPV left inferior pulmonary vein; LSPV left superior pulmonary vein; RIPV right inferior pulmonary vein; RSPV right superior pulmonary vein). However, after bolus intravenousinjectionof ATP 20 mg to induce atrial stasis by creating complete AV block, all the ostia and major branches of the PVs could be clearly identied (Fig. right). This technique can be used to identify the ostia of the PVs for catheter positioning during the procedure and to assess changes in PV size after radiofre- quency ablation. References 1. Haõ ¨ssaguerre M, Jaõ ¨s P, Shah DC, Takahashi A, Hocini M, Quiniou G, Garrigue S, Le Mouroux A, Le Metayer P, Clementy J: Spontaneous initiation of atrial brillation by ectopic beats originating in the pul- monary veins. N Engl J Med 1998;339:659-666. 2. Lau CP, Tse HF, Ayers GM: Debrillation-guided radiofrequency ablation of atrial brillation secondary to an atrial focus. J Am Coll Cardiol 1999;33:1217-1226. 3. Chen SA, Hsieh MH, Tai CT, Tsai CF, Prakash VS, Yu WC, Hsu TL, Ding YA, Chang MS: Initiation of atrial brillation by ectopic beats originating from the pulmonary veins: Electrophysiological character- istics, pharmacological responses, and effects of radiofrequency abla- tion. Circulation 1999;100:1879-1886. 4. Tse HF, Lau CP, Kou W, Pelosi F, Oral H, Kim M, Michaud GF, Knight BP, Moscucci M, Strickberger SA, Morady F: Comparison of endocardial activation times at effective and ineffective ablation sites within the pulmonary veins. J Cardiovasc Electrophysiol 2000;11:155-159. 5. Haissaguerre M, Shah DC, Jais P, Hocini M, Yamane T, Deisenhofer I, Chauvin M, Garrigue S, Clementy J: Electrophysiological break- throughs from the left atrium to the pulmonary veins. Circulation 2000;102:2463-2465. 6. Pappone C, Rosanio S, Oreto G, Tocchi M, Gugliotta F, Vicedomini G, Salvati A, Dicandia C, Mazzone P, Santinelli V, Gulletta S, Chier- chia S: Circumferential radiofrequency ablation of pulmonary vein ostia: A new anatomic approach for curing atrial brillation. Circula- tion 2000;102:2619-2628. J Cardiovasc Electrophysiol, Vol. 13, p. 300, March 2002. Address for correspondence: Chu-Pak Lau, M.D., Cardiology Division, Department of Medicine, Queen Mary Hospital, Hong Kong. Fax: 852- 2818-6304; E-mail: cplau@hkucc.hku.hk 300 Reprinted with permission from JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Volume 13, No. 3, March 2002 Copyright ©2002 by Futura Publishing Company, Inc., Armonk, NY 10504-0418