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J Am Coll Cardiol, 2004; 44:1071-1079, doi:10.1016/j.jacc.2004.05.072
© 2004 by the American College of Cardiology Foundation
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ARRHYTHMIAS

Left atrial tachycardia after circumferential pulmonary vein ablation for atrial fibrillation

Electroanatomic characterization and treatment

C.ézar E. Mesas, MD, Carlo Pappone, MD, PhD*,, Christopher C.E. Lang, MB, ChB, Filippo Gugliotta, BEng, Takeshi Tomita, MD, PhD, Gabriele Vicedomini, MD, Simone Sala, MD, Gabriele Paglino, MD, Simone Gulletta, MD, Amedeo Ferro, MD and Vincenzo Santinelli, MD

Department of Cardiology, Arrhythmology Section, San Raffaele University Hospital, Milan, Italy

Manuscript received April 2, 2004; accepted May 25, 2004.

* Reprint requests and correspondence: Dr. Carlo Pappone, Department of Cardiology, San Raffaele University Hospital, Via Olgettina 60, 20132, Milan, Italy (Email: carlo.pappone{at}hsr.it).

OBJECTIVES: The purpose of this study was to evaluate the electroanatomic characteristics of left atrial tachycardia (AT) in a series of patients who underwent circumferential pulmonary vein ablation (CPVA) and to describe the ablation strategy and clinical outcome.

BACKGROUND: Circumferential pulmonary vein ablation is an effective treatment for atrial fibrillation. A potential midterm complication is the development of left AT. There are only isolated reports describing mapping and ablation of such arrhythmias.

METHODS: Thirteen patients (age 57.4 ± 8.9 years, five female) underwent mapping and ablation of 14 left ATs via an electroanatomic mapping system a mean of 2.6 ± 1.6 months after CPVA.

RESULTS: Three patients were characterized as having focal AT (cycle length: 266 ± 35.9 ms). Of 11 macro–re-entrant tachycardias studied in the remaining 10 patients (cycle length: 275 ± 75 ms), 5 showed single-loop and 6 dual-loop circuits. Re-entrant circuits used the mitral isthmus, the posterior wall, or gaps on previous encircling lines. Such gaps and all three foci occurred anterior to the left superior pulmonary vein or at the septal aspect of the right pulmonary veins. Thirteen of 14 tachycardias (93%) were successfully ablated.

CONCLUSIONS: Left AT after CPVA can be due to a macro–re-entrant or focal mechanism. Re-entry occurs most commonly across the mitral isthmus, the posterior wall, or gaps on previous ablation lines. Such gaps and foci occur most commonly at the anterior aspect of the left superior pulmonary vein and at the septal aspect of the right pulmonary veins. These arrhythmias can be successfully mapped and ablated with an electroanatomic mapping system.

Abbreviations and Acronyms
  AF = atrial fibrillation
  AT = atrial tachycardia
  CPVA = circumferential pulmonary vein ablation
  ESA = electrically silent area
  LA = left atrial/atrium
  LSPV = left superior pulmonary vein
  PV = pulmonary vein
  RF = radiofrequency




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