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J Am Coll Cardiol, 2005; 46:83-91, doi:10.1016/j.jacc.2005.03.053
© 2005 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Catheter Ablation of Atypical Atrial Flutter and Atrial Tachycardia Within the Coronary Sinus After Left Atrial Ablation for Atrial Fibrillation

Aman Chugh, MD*, Hakan Oral, MD, FACC, Eric Good, DO, Jihn Han, MD, Kamala Tamirisa, MD, Kristina Lemola, MD, Darryl Elmouchi, MD, David Tschopp, MD, Scott Reich, MD, Petar Igic, MD, Frank Bogun, MD, Frank Pelosi, Jr, MD, FACC and Fred Morady, MD, FACC

Division of Cardiology, University of Michigan Hospitals, Ann Arbor, Michigan.

Manuscript received February 1, 2005; revised manuscript received March 13, 2005, accepted March 15, 2005.

* Reprint requests and correspondence: Dr. Aman Chugh, Cardiology, TC B1 D140, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109-0311. (Email: achugh{at}umich.edu).

OBJECTIVES: The goal of this study was to describe the prevalence and ablation of coronary sinus (CS) arrhythmias after left atrial ablation for atrial fibrillation (AF).

BACKGROUND: The CS has been implicated in a variety of supraventricular arrhythmias.

METHODS: Thirty-eight patients underwent mapping and ablation of atypical flutter that developed during (n = 5) or after (n = 33) ablation for AF. Also included were two patients with focal CS arrhythmias that occurred during an AF ablation procedure. A tachycardia was considered to be originating from the CS if the post-pacing interval in the CS matched the tachycardia cycle length and/or if it terminated during ablation in the CS.

RESULTS: Among the 33 patients who developed atypical flutter late after AF ablation, 9 (27%) were found to have a CS origin. Overall, 16 of the 40 patients in this study had a CS arrhythmia. The tachycardia was macro-re-entrant in 14 patients (88%) and focal in two patients. Radiofrequency ablation with an 8-mm-tip catheter was successful in 15 patients (94%) without complication. In eight patients (50%), ≥45 W was required for successful ablation. Thirteen of the 15 patients (87%) with a successful ablation acutely remained arrhythmia-free during 5 ± 5 months of follow-up.

CONCLUSIONS: The musculature of the CS serves as a critical component of the re-entry circuit in approximately 25% of patients with atypical flutter after ablation for AF. The CS may also generate focal atrial arrhythmias that may play a role in triggering and/or maintaining AF. Catheter ablation of these arrhythmias in the CS can be performed safely.

Abbreviations and Acronyms
  AF = atrial fibrillation
  CS = coronary sinus
  ECG = electrocardiogram
  PPI = post-pacing interval




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