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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Substrate Mapping to Detect Abnormal Atrial Endocardium With Slow Conduction in Patients With Atypical Right Atrial Flutter

Jin Long Huang, MD, PhD^_*,, Ching-Tai Tai, MD^_*,, Yenn-Jiang Lin, MD^_*,, Bien-Hsien Huang, MD^_*,, Kun-Tai Lee, MD^_*,, Satoshi Higa, MD^_*,, Yoga Yuniadi, MD^_*,, Yi-Jen Chen, MD, PhD^_*,, Shih-Lin Chang, MD^_*,, Li-Wei Lo, MD^_*,, Wanwarang Wongcharoen, MD^_*,, Chih-Tai Ting, MD, PhD^_*, and Shih-Ann Chen, MD^_*,,_*

^_* Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
Division of Cardiology, Department of Medicine, Veterans General Hospital-Taipei, Taipei, Taiwan.

Manuscript received January 6, 2006; revised manuscript received March 3, 2006, accepted March 8, 2006.

^_* Reprint requests and correspondence: Dr. Shih-Ann Chen, Division of Cardiology, Veterans General Hospital-Taipei, 201 Sec. 2, Shih-Pai Road, Taipei, Taiwan. (Email: epsachen{at}ms41.hinet.net).

OBJECTIVES: The purpose of this study was to investigate the relationship between the abnormal substrate and peak negative voltage (PNV) in the right atrium (RA) with atypical flutter.

BACKGROUND: The impact of a local abnormally low voltage electrogram on the local activation pattern and velocity of atrial flutter (AFL) remains unclear.

METHODS: Twelve patients with clinically documented AFL were included to undergo noncontact mapping of the RA. The atrial substrate was characterized by the: 1) activation mapping; 2) high-density voltage mapping; and 3) conduction velocity along the flutter re-entrant circuit. The normalized PNV (i.e., the relative ratio to the maximal PNV) in each virtual electrode recording was used to produce the voltage maps of the entire chamber. The protected isthmus was bordered by low voltage zones.

RESULTS: Atypical AFL of the RA was induced by atrial pacing in 12 patients, including 10 upper loop re-entry and 2 RA free wall re-entry flutter. These protected isthmuses were located near the crista terminalis. The mean width of the protected isthmus was 1.7 ± 0.3 cm and mean voltage at the isthmus was –0.91 ± 0.39 mV. The conduction velocities within these paths were significantly slower than outside the path (0.30 ± 0.18 m/s vs. 1.14 ± 0.41 m/s, respectively; p = 0.004). The ratiometric PNV of 37.6% of the maximal PNV had the best cut-off value to predict slow conduction, with a high sensitivity (92.3%) and specificity (85.7%).

CONCLUSIONS: Characterization of the RA substrate in terms of the unipolar PNV is an effective predictor of the slow conduction path within the critical isthmus of the re-entrant circuit.

Abbreviations and Acronyms   AFL = atrial flutter   CS = coronary sinus   CTI = cavotricuspid isthmus   LAL = low anterolateral   LVZ = low voltage zone   MEA = multielectrode array   NCM = noncontact mapping   PNV = peak negative voltage   RA = right atrium   3D = 3-dimensional

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