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CLINICAL RESEARCH: ELECTROPHYSIOLOGY

Functional characterization of the crista terminalis in patients with atrial flutter: implications for radiofrequency ablation

Tu-Ying Liu, MD^*, Ching-Tai Tai, MD^*,*, Bien-Hsien Huang, MD, Satoshi Higa, MD, Yenn-Jiang Lin, MD^*, Jin-Long Huang, MD^*, Yoga Yuniadi, MD, Pi-Chang Lee, MD^*, Yu-An Ding, MD^* and Shih-Ann Chen, MD^*

^* National Yang-Ming University School of Medicine, Taipei, Taiwan
Division of Cardiology, Department of Medicine, Chutung Veterans Hospital, Chutung, Taiwan
Taipei Veterans General Hospital, Taipei, Taiwan

Manuscript received August 3, 2003; revised manuscript received October 30, 2003, accepted November 25, 2003.

^* Reprint requests and correspondence: Dr. Ching-Tai Tai, Division of Cardiology, Taipei Veterans General Hospital, 201 Sec. 2, Shih-Pai Road, Taipei, Taiwan.
ct.tai{at}msa.hinet.net

OBJECTIVES: The aim of the study was to investigate the conduction properties and anisotropy of the crista terminalis (CT) in patients with atrial flutter (AFL) using non-contact mapping.

BACKGROUND: The CT is a posterior barrier during typical AFL. However, the CT has transverse conduction capabilities in patients with upper loop re-entry (ULR).

METHODS: Twenty-two patients (16 males, 63 ± 15 years) with typical AFL and ULR were included. Non-contact mapping of the right atrium during AFL and pacing from coronary sinus (CS) and low anterolateral right atrium (LARA) was performed to evaluate transverse conduction across the CT. During ULR, the longitudinal (CV_L) and transverse (CV_T) conduction velocity along and across the CT were measured. The width of the CT conduction gap was evaluated to guide radiofrequency ablation (RFA).

RESULTS: No transverse CT gap conduction was found during typical AFL. Transverse CT gap conduction was found in three patients during CS pacing and in three patients during LARA pacing. During ULR, CV_L was greater than CV_T (1.28 ± 0.43 vs. 0.73 ± 0.30 m/s, p < 0.001). The CV_L/CV_T ratio was 1.95 ± 0.77, which was inversely related to the CT gap width (15.7 ± 6.8 mm) (p < 0.001). The RFA of the CT gap was successful in 18 patients. Four patients had recurrence of arrhythmias during the follow-up of 11 ± 3 months.

CONCLUSIONS: Most of the CT conduction gaps were functional and only appeared during ULR. The width of the CT gap was inversely related to the anisotropic ratio of the CT. The RFA of the CT gap was effective in eliminating ULR.

Abbreviations and Acronyms   AFL = atrial flutter   CS = coronary sinus   CT = crista terminalis   CTI = cavotricuspid isthmus   CV = conduction velocity   LARA = low anterolateral right atrium   MEA = multielectrode array   RA = right atrium   RFA = radiofrequency ablation   ULR = upper loop re-entry

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