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J Am Coll Cardiol, 2002; 39:896-906
© 2002 by the American College of Cardiology Foundation
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CLINICAL STUDY: ELECTROPHYSIOLOGY

Sensitivity and specificity of concealed entrainment for the identification of a critical isthmus in the atrium: relationship to rate, anatomic location and antidromic penetration

Joseph B. Morton, MBBSa, Prashanthan Sanders, MBBSa, Vincent Deen, MBBSa, Jithendra K. Vohra, MD, FACCa and Jonathan M. Kalman, MBBS, PhD, FACC*,a

a Department of Cardiology, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia

Manuscript received September 11, 2001; revised manuscript received December 3, 2001, accepted December 14, 2001.

* Reprint requests and correspondence: Prof. Jonathan M. Kalman, Department of Cardiology, The Royal Melbourne Hospital, Grattan Street, Parkville 3050, Melbourne, Australia
jon.kalman{at}mh.org.au

OBJECTIVES

This study was designed to determine the sensitivity and specificity of concealed entrainment (CE) for the identification of a critical isthmus in the atrium.

BACKGROUND

Isthmus identification during entrainment mapping of macro-reentrant atrial tachycardia (MRAT) relies on the demonstration of CE.

METHODS

Using the model of typical atrial flutter, entrainment was performed in 10 patients at four rates (flutter cycle length [FCL] minus 10/20/30/40 ms) from seven sites: isthmus entrance/exit, low lateral/high lateral/high septal right atrium and proximal/distal coronary sinus. Surface 12-lead electrocardiogram fusion was evaluated by three observers blind to patient status. The extent of antidromic penetration (AP) was measured off the pacing catheter positioned around the tricuspid annulus.

RESULTS

The sensitivity for CE identifying any isthmus site was greatest at FCL–10 (100%), but the specificity was poor (54%). Conversely, specificity was greatest at FCL–40 (98%), but the sensitivity was poor (65%), with manifest entrainment (ME) observed from the isthmus entrance in 70% of episodes. At FCL–30, sensitivity (85%) and specificity (90%) were "balanced," but CE still resulted during entrainment from a non-isthmus site in five of 10 patients. Antidromic penetration increased with pacing CL shortening (p < 0.001) and correlated with the development of ME (p < 0.001). Antidromic penetration was significantly blunted from the isthmus exit compared to all other sites (p = 0.003).

CONCLUSIONS

The sensitivity and specificity of CE for identifying an isthmus in the atrium are critically dependent on the pacing rate and the precise anatomic pacing site within the isthmus. These findings may have implications for the use of entrainment in the mapping of unknown MRAT circuits.

Abbreviations and Acronyms
  AFL = atrial flutter
  AP = antidromic penetration
  AV = atrioventricular
  CE = concealed entrainment
  CS = coronary sinus
  DCS = distal coronary sinus
  ECG = electrocardiogram
  FCL = flutter cycle length
  HLRA = high lateral right atrium
  HSRA = high septal right atrium
  LAO = left anterior oblique
  LLRA = low lateral right atrium
  ME = manifest entrainment
  PCS = proximal coronary sinus
  PPI = post-pacing interval
  RA = right atrium
  RFA = radiofrequency ablation
  TA = tricuspid annulus
  TCL = tachycardia cycle length




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[Abstract] [Full Text] [PDF]




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