Importance of ablating all potential right atrial flutter circuits in postcardiac surgery patients
Atul Verma, MD*,
Nassir F. Marrouche, MD*,*,
Niranjan Seshadri, MD*,
Robert A. Schweikert, MD*,
Mandeep Bhargava, MD*,
J. David Burkhardt, MD*,
Fethi Kilicaslan, MD*,
Jennifer Cummings, MD*,
Walid Saliba, MD* and
Andrea Natale, MD*
* Department of Cardiology, Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Figure 1 Surface electrocardiograms (I, aVF, V1, V6) of both cavotricuspid isthmus (CTI)-dependent and scar-related atrial flutters in a single patient. In this patient, the presenting flutter was CTI-dependent moving in a classic clockwise direction with a cycle length of 245 ms (A). Although this flutter was successfully ablated with an isthmus ablation line, a second flutter was induced after ablation (B). Although the cycle length of this flutter is similar, the morphology and axis of the P waves is clearly different. This flutter was mapped and found to be coming from a re-entry circuit involving the incisional scar. Creating an ablation line from the incisional scar to the tricuspid annulus terminated this second flutter.
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Figure 2 Three-dimensional electroanatomic activation maps of both scar-related and cavotricuspid isthmus (CTI)-dependent flutters in the same patient. In this patient, electroanatomic mapping using the CARTO system demonstrated that the clinical flutter involved a re-entry circuit moving circumferentially around the incisional scar (A). The arrow in A indicates the direction of movement of activation from earliest to latest for this scar-related flutter. This flutter was successfully ablated by creating an ablation line from the scar to the tricuspid annulus (B, line 1). However, a second, CTI-dependent flutter was induced moving in a clockwise direction as indicated by the arrow in B. This flutter required a second isthmus ablation line to be created from the tricuspid annulus to the inferior vena cava (IVC) (B, line 2). TV = tricuspid valve.
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