Atrial Tachycardia Arising From the Coronary Sinus Musculature
Electrophysiological Characteristics and Long-Term Outcomes of Radiofrequency Ablation
Nitish Badhwar, MBBS, FACC*,
Jonathan M. Kalman, MBBS, PhD, FACC ,
Paul B. Sparks, MBBS, PhD,
Peter M. Kistler, MBBS,
Mehran Attari, MD ,
Marcie Berger, MD, FACC,
Randall J. Lee, MD, PhD, FACC*,
Jasbir Sra, MD, FACC and
Melvin M. Scheinman, MD, FACC*,*
* University of California, San Francisco, San Francisco, California
Royal Melbourne Hospital, Melbourne, Australia
Aurora Sinai/St. Luke’s Medical Centers, University of Wisconsin Medical School-MCC, Milwaukee, Wisconsin
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Figure 1 A 12-lead electrocardiogram showing P-wave morphology during atrial tachycardia in a patient with adenosine-induced atrioventricular block. The P waves are inverted in II, III, and avF. The precordial leads show positive P-wave in V1, inverted in V6, with a transition at V4. Lead avL shows an initial positive component followed by a negative component.
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Figure 2 (A) Intracardiac recording during sinus rhythm in a patient showing a characteristic potential (P) following the coronary sinus (CS) atrial electrogram (A) (arrows). (B) Intracardiac recording during tachycardia showing the CS (P) now preceding the CS (A) (arrows).
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Figure 3 (A) Intracardiac recording during tachycardia with the ablator catheter at the mitral annulus showing the earliest activation in the left atrium. (B) Ablation performed at this site leads to prolongation of cycle length and termination of tachycardia with dissociation of coronary sinus (CS) potential (arrows). The interval between the last two atrial complexes during tachycardia is identical to the interval between the recorded CS potential. (C) Intracardiac recording during sinus rhythm showing CS potential (arrows) is now dissociated from CS atrial electrogram and identical to the tachycardia cycle length. This suggests that the CS potential is the site of origin of the tachycardia.
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Figure 4 The ablator catheter (ABL) is at the mitral annulus showing the earliest endocardial recording in the left atrium during tachycardia. This was always preceded by atrial recording in the coronary sinus (CS). Left anterior oblique projection of the catheter position is shown on the right.
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Figure 5 (A) CARTO map of the left atrium in the posteroanterior (PA) view in one patient. This is consistent with focal activation pattern with a broad area of early activation (red) at the posterior lateral mitral annulus. (B) CARTO map of the left atrium in the left anterior oblique (LAO) view in another patient. This is also consistent with a focal activation pattern and a broad area of early activation (red) at the posterior lateral mitral annulus.
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Figure 6 Simultaneous CARTO map of the left atrium (LA) and the coronary sinus (Cs) during tachycardia showing focal activation pattern. The distal part of the Cs (red) shows earliest activation, and the LA (purple) shows the latest activation. AP = anteroposterior; PA = posterioanterior.
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Figure 7 Propagation map of the coronary sinus (CS) and left atrium during tachycardia. The upper panel shows the anteroposterior (AP) view followed by the posteroanterior (PA) view in the lower panel. This map clearly shows the earliest activation in the distal CS followed by activation of the rest of the CS musculature and finally spread of activation to the left atrium. This suggests focal origin of the tachycardia from the CS musculature.
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