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CLINICAL RESEARCH: HEART RHYTHM DISORDERS

Focal Atrial Tachycardia From the Ostium of the Coronary Sinus

Electrocardiographic and Electrophysiological Characterization and Radiofrequency Ablation

Department of Cardiology, Royal Melbourne Hospital and the Department of Medicine, University of Melbourne, Melbourne, Australia.

Manuscript received October 13, 2004; revised manuscript received January 3, 2005, accepted January 11, 2005.

^_* Reprint requests and correspondence: Dr. Jonathan M. Kalman, Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia 3050. (Email: jon.kalman{at}mh.org.au).

OBJECTIVES: The goal of this study was to characterize the electrocardiographic and electrophysiologic features and frequency of focal atrial tachycardia (AT) originating from the coronary sinus ostium (CS).

BACKGROUND: The ostium of the coronary sinus has been described as a site of origin of AT, but detailed characterization of these tachycardias is limited.

METHODS: Thirteen patients (6.7%) of 193 undergoing radiofrequency ablation (RFA) for focal AT are reported. Endocardial activation maps (EAM) were recorded from catheters at the CS (10 pole), crista terminalis (20 pole), and His positions. The P waves were classified negative, positive, isoelectric, or biphasic.

RESULTS: The mean age was 41 ± 6 years, seven female patients, with symptoms for 8 ± 3 years. Tachycardia was induced by programmed extra-stimuli in eight patients, was spontaneous in three patients, and in response to isoproterenol in two patients. These foci had a characteristic P-wave morphology. At the CS ostium, the P-wave was deeply negative in all inferior leads, negative or isoelectric becoming positive in lead V₁, then progressively negative across the precordium. Lead aVL was positive in all patients. Earliest EAM activity occurred at the proximal CS at 20 ± 3 ms ahead of P-wave. Mean activation time at the successful RFA site = –36 ± 8 ms; RFA was acutely successful in 11 of 13 patients. Long-term success was achieved in 11 of 11 over a median follow-up of 25 ± 4 months.

CONCLUSIONS: The CS ostium is an uncommon site of origin for focal AT (6.7%). It can be suspected as a potential anatomic site of AT origin from the characteristic P-wave and activation timing. Long-term success was achieved with focal ablation in the majority of patients.

Abbreviations and Acronyms   AT = atrial tachycardia   AV = atrioventricular   CS = coronary sinus   CT = crista terminalis   RA = right atrium   RFA = radiofrequency ablation

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