Non-contact mapping to guide radiofrequency ablation of atypical right atrial flutter
Ching-Tai Tai, MD*,
Tu-Ying Liu, MD,
Pi-Chang Lee, MD,
Yenn-Jiang Lin, MD,
Mau-Song Chang, MD and
Shih-Ann Chen, MD
Division of Cardiology, Department of Medicine, National Yang-Ming University School of Medicine, Taipei Veterans General Hospital, Taiwan, Republic of China
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Figure 1 The 12-lead surface electrocardiograms of atypical right atrial flutters. (A) Single-loop re-entry. The flutter waves are positive in leads II, III, aVF and positive in lead V1. (B) Type I figure-of-eight re-entry. The flutter waves are positive in leads II, III, aVF and biphasic in lead V1. (C) Type II figure-of-eight re-entry. The flutter waves are negative in leads II, III, aVF and positive in lead V1.
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Figure 2 Isopotential maps showing the activation sequence (frames 1 to 6) of single-loop re-entry in the right lateral view. Color scale for each isopotential map has been set so that white indicates most negative potential and blue indicates least negative potential. The activation wave front proceeds through the channel between the CT and the central obstacle (frame 1), activates the low anterior wall (frame 2), and turns around the line of block (frame 3). Then the wave front propagates upward to the roof in front of the right atrial appendage (frame 4), turns around the superior vena cava (SVC) to activate the posterior wall (frame 5), and spreads over the top of the crista terminalis (CT) to complete the re-entrant circuit (frame 6). The virtual electrograms (virtual 10 to 14) on the line of block showed double potentials. HIS = His bundle region; IVC = inferior vena cava; RAA = right atrial appendage; TV= tricuspid valve.
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Figure 3 Isochronal map showing type I figure-of-eight re-entry in the right posterior oblique view. The activation wave front propagated through the conduction gap in the crista terminalis (CT) and separated into two wave fronts. The counterclockwise wave front (virtual 8 to 13) rotated around the superior vena cava (SVC) and upper CT, and the clockwise wave front (virtual 14 to 18) rotated around the inferior vena cava (IVC) and lower CT. The virtual electrogram 9 at the CT gap showed low amplitude potential between double potentials, representing slow conduction. RAA = right atrial appendage.
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Figure 4 Isochronal map showing type II figure-of-eight re-entry in the right posterior oblique view. The activation wave front propagated through the channel between two central obstacles. One is located in the crista terminalis (virtual 10 to 13), and the other is located in the anterolateral wall combined with the right atrial appendage (virtual 14 to 17). The counterclockwise wave front rotated around the anterior free-wall obstacle, whereas the clockwise wave front rotated around the crista terminalis. IVC = inferior vena cava; RAA = right atrial appendage; SVC = superior vena cava; TV= tricuspid valve.
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