Catheter ablation of atrioatrial conduction as a cure for atrial arrhythmia after orthotopic heart transplantation1
Nadir Saoudi, MD, FACCa,
Michel Redonnet, MDa,
Frederic Anselme, MDa,
Hervé Poty, MDa and
Alain Cribier, MD, FACCa
a Service de Cardiologie, Hopital Charles Nicolle, University of Rouen, Rouen, France
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Figure 1 Patient 1: intracardiac recordings during grafted right atrial sinus rhythm (upper panel) and recipient sinus rhythm (lower panel). In both cases the other atrium follows the dominant one. When the grafted sinus rhythm is dominant, the P wave is almost flat, its end is not discernible and the PR interval is 140 ms. On the other hand, when the recipient sinus rhythm takes over, the P wave and PR interval are tremendously distorted and prolonged (280 and 312 ms, respectively). RRA = recipient right atrium, GRA = grafted right atrium.
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Figure 2 Patient 2: surface ECG pattern of atrial extrasystoles due to recipient to grafted atrioatrial conduction.
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Figure 3 Patient 2: (A) Grafted atrial trigeminy due to regular capture by the recipient right atrium. (B) 1:1 conduction to the grafted right atrium during recipient incremental right atrial pacing at a cycle length of 500 ms. (C) Complete grafted-recipient atrioatrial dissociation during programmed stimulation of the grafted atrium with induction of common atrial flutter.
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Figure 4 Patient 3: intracardiac recording of native to grafted (left) and grafted to native (right) atrioatrial conduction. HBE = His bundle electrogram. Two different P waves are observed as a function of the "leading" atrium.
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Figure 5 Patient 3: induced atrial tachycardia with 2:1 and 1:1 atrioatrial conduction from the recipient to the grafted right atrium.
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Figure 6 Patient 1: local electrogram at the successful ablation site during spontaneous grafted to recipient atrioatrial conduction. Proximal and distal recording bipoles of the ablation catheter are straddling the suture line based on electrogram amplitude (see text for discussion). Abl = ablation catheter recording bipole; d = distal, p = proximal.
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Figure 7 Patient 1: complete atrioatrial dissociation after a single radiofrequency pulse.
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Figure 8 Patient 2: pace mapping of atrioatrial conduction. Left panel: The pacing electrode is in the low recipient atrium. In the inferior leads a negative P wave is followed by an isoelectric component that precedes a positive P wave. The time separating the pacing artifact from the resulting grafted P wave is 180 ms. This suggests that the paced impulse had to first depolarize the recipient right atrium in an ascending fashion. After a delay due to slow conduction at an upper right atrial site, depolarization of the grafted right atrium then ensued descendingly. Right panel: the pacing electrode is now in the high recipient atrium close to the suture line at the successful ablation site. The resulting P wave follows the pacing spike without intervening initial negativity, and after a 50-ms delay.
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Figure 9 Patient 3: disappearance of atrioatrial conduction within 2 s of the radiofrequency pulse during grafted atrial pacing at a cycle length of 520 ms. Note the change in P wave morphology with interruption of atrioatrial conduction. Complete electrical isolation of both atria is now visible on the surface electrocardiogram.
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