Skip to main content
Log in

Endocardial voltage mapping of pulmonary veins with an ultra-high-resolution system to evaluate atrial myocardial extensions

  • Original Paper
  • Published:
Clinical Research in Cardiology Aims and scope Submit manuscript



Atrial fibrillation (AF) is mainly triggered by arrhythmogenic foci originating from atrial myocardial extensions (MEs) into the pulmonary veins (PVs). Aim of the study was to evaluate endocardial voltage maps of PVs as a surrogate parameter for the extent of MEs in subjects with AF through a ultra-high-density mapping system.


Sixty-four bipolar electrograms were recorded simultaneously from the Orion mini-basket catheter placed in 72 PVs of 18 consecutive patients with paroxysmal/persistent AF undergoing PV isolation (PVI). The Rhythmia system in conjunction with the Orion mini-basket catheter was utilized to create a bipolar electro-anatomic reconstruction of the left atrium and PVs.


Mean patients’ age was 61 ± 10 years, 56% had paroxysmal and 44% persistent AF. Mean endocardial bipolar voltages in the PVs were as follows: 1.06 ± 0.34 mV in right superior PV, 1.14 ± 0.52 mV in right inferior PV, 1.15 ± 0.44 mV in left superior PV and 0.94 ± 0.44 in left inferior PV. PVs had no detectable endocardial signals in 7 out of 72 PVs (9%); a total of 29/72 PVs (40%) revealed a non-uniform arrangement of MEs. The area of MEs was significantly larger in the superior PVs compared to the inferior PVs (9.3 ± 4.7 vs 6.7 ± 4 cm2, p = 0.002). No statistical differences in terms of MEs length were found among PVs and according to type of AF.


In this pilot study using a ultra-high-resolution electro-anatomical mapping system, endocardial voltage maps of PVs as a surrogate parameter of MEs among patients with AF well correspond to previous data from histopathological studies.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others


  1. Miyasaka Y, Barnes ME, Gersh BJ et al (2006) Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 114:119–125

    Article  PubMed  Google Scholar 

  2. Haissaguerre M, Jais P, Shah DC et al (1998) Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 339:659–666

    Article  CAS  PubMed  Google Scholar 

  3. Kholova I, Kautzner J (2003) Anatomic characteristics of extensions of atrial myocardium into the pulmonary veins in subjects with and without atrial fibrillation. Pacing Clin Electrophysiol 26:1348–1355

    Article  PubMed  Google Scholar 

  4. Saito T, Waki K, Becker AE (2000) Left atrial myocardial extension onto pulmonary veins in humans: anatomic observations relevant for atrial arrhythmias. J Cardiovasc Electrophysiol 11:888–894

    Article  CAS  PubMed  Google Scholar 

  5. Hassink RJ, Aretz HT, Ruskin J, Keane D (2003) Morphology of atrial myocardium in human pulmonary veins: a postmortem analysis in patients with and without atrial fibrillation. J Am Coll Cardiol 42:1108–1114

    Article  PubMed  Google Scholar 

  6. Thajudeen A, Jackman WM, Stewart B, Cokic I, Nakagawa H, Shehata M, Amorn AM, Kali A, Liu E, Harlev D, Bennett N, Dharmakumar R, Chugh SS, Wang X (2015) Correlation of scar in cardiac MRI and high-resolution contact mapping of left ventricle in a chronic infarct model. Pacing Clin Electrophysiol 38:663–674

    Article  PubMed  PubMed Central  Google Scholar 

  7. Calkins H, Kuck KH, Cappato R et al (2012) 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace 14:528–606

    Article  PubMed  Google Scholar 

  8. Ouyang F, Tilz R, Chun J, Schmidt B, Wissner E, Zerm T, Neven K, Köktürk B, Konstantinidou M, Metzner A, Fuernkranz A, Kuck KH (2010) Long-term results of catheter ablation in paroxysmal atrial fibrillation: lessons from a 5-year follow-up. Circulation 122:2368–2377

    Article  PubMed  Google Scholar 

  9. Nakagawa H, Ikeda A, Sharma T, Lazzara R, Jackman WM (2012) Rapid high resolution electroanatomical mapping: evaluation of a new system in a canine atrial linear lesion model. Circ Arrhythm Electrophysiol 5:417–424

    Article  PubMed  Google Scholar 

  10. Bollmann A, Hilbert S, John S, Kosiuk J, Hindricks G (2016) Initial experience with ultra high-density mapping of human right atria. J Cardiovasc Electrophysiol 27:154–160

    Article  PubMed  Google Scholar 

  11. Sohns C, Saguner AM, Lemes C, Santoro F, Mathew S, Heeger C, Reißmann B, Maurer T, Riedl J, Fink T, Hayashi K, Ouyang F, Kuck KH, Metzner A (2016) First clinical experience using a novel high-resolution electroanatomical mapping system for left atrial ablation procedures. Clin Res Cardiol. doi:10.1007/s0039-016-1008-7

    PubMed Central  Google Scholar 

  12. Anter E, Tschabrunn CM, Contreras-Valdes FM, Li J, Josephson ME (2015) Pulmonary vein isolation using the Rhythmia mapping system: verification of intracardiac signals using the Orion mini-basket catheter. Heart Rhythm 12:1927–1934

    Article  PubMed  Google Scholar 

  13. Teh AW, Kistler PM, Lee G, Medi C, Heck PM, Spence S, Morton JB, Sanders P, Kalman JM (2011) Electroanatomic properties of the pulmonary veins: slowed conduction, low voltage and altered refractoriness in AF patients. J Cardiovasc Electrophysiol 22:1083–1091

    Article  PubMed  Google Scholar 

  14. Teh AW, Kalman JM, Lee G, Medi C, Heck PM, Ling LH, Kumar S, Spence SJ, Morton JB, Kistler PM (2012) Electroanatomic remodelling of the pulmonary veins associated with age. Europace 14:46–51

    Article  PubMed  Google Scholar 

  15. DeSimone CV, Noheria A, Lachman N, Edwards WD, Gami AS, Maleszewski JJ, Friedman PA, Munger TM, Hammill SC, Packer DL, Asirvatham SJ (2012) Myocardium of the superior vena cava, coronary sinus, vein of Marshall, and the pulmonary vein ostia: gross anatomic studies in 620 hearts. J Cardiovasc Electrophysiol 23:1304–1309

    Article  PubMed  Google Scholar 

  16. Klika E, Zajícová A (1980) The occurrence of the myocardial coat of pulmonary veins in various species of mammals. Folia Morphol 28:381–384

    CAS  Google Scholar 

  17. Tagawa M, Higuchi K, Chinushi M, Washizuka T, Ushiki T, Ishihara N, Aizawa Y (2001) Myocardium extending from the left atrium onto the pulmonary veins: a comparison between subjects with and without atrial fibrillation. Pacing Clin Electrophysiol 24:1459–1463

    Article  CAS  PubMed  Google Scholar 

  18. Lin WS, Prakash VS, Tai CT et al (2000) Pulmonary vein morphology in patients with paroxysmal atrial fibrillation initiated by ectopic beats originating from the pulmonary veins: implications for catheter ablation. Circulation 101:1274–1281

    Article  CAS  PubMed  Google Scholar 

  19. Chen SA, Hsieh MH, Tai CT et al (1999) Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation 100:1879–1886

    Article  CAS  PubMed  Google Scholar 

  20. Roux N, Havet E, Mertl P (2004) The myocardial sleeves of the pulmonary veins: potential implications for atrial fibrillation. Surg Radiol Anat 26:285–289

    Article  CAS  PubMed  Google Scholar 

  21. Makimoto H, Heeger CH, Lin T, Rillig A, Metzner A, Wissner E, Mathew S, Deiss S, Rausch P, Lemeš C, Kuck KH, Ouyang F, Tilz RR (2015) Comparison of contact force-guided procedure with non-contact force-guided procedure during left atrial mapping and pulmonary vein isolation: impact of contact force on recurrence of atrial fibrillation. Clin Res Cardiol 104(10):861–870

    Article  PubMed  Google Scholar 

  22. Wasmer K, Dechering DG, Köbe J, Mönnig G, Pott C, Frommeyer G, Lange PS, Kochhäuser S, Eckardt L (2016) Pulmonary vein reconnection and arrhythmia progression after antral linear catheter ablation of paroxysmal and persistent atrial fibrillation. Clin Res Cardiol 105(9):738–743

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Francesco Santoro.

Ethics declarations

Conflict of interest

Dr. Santoro received a research grant from the Italian Society of Cardiology supported by Msd Italia-Merck Sharp & Dohme Corporation. Dr. Saguner received speaker’s honoraria from Boston Scientific. Prof. Dr. KH Kuck received honoraria from Biosense Webster, Medtronic and St. Jude Medical. Dr. Metzner received speaker’s honoraria from Medtronic, Biosense Webster and Cardiofocus. All other authors have no relevant disclosures.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Santoro, F., Sohns, C., Saguner, A.M. et al. Endocardial voltage mapping of pulmonary veins with an ultra-high-resolution system to evaluate atrial myocardial extensions. Clin Res Cardiol 106, 293–299 (2017).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: