Focal Atrial Tachycardia Originating From the Non-Coronary Aortic Sinus
Electrophysiological Characteristics and Catheter Ablation
Feifan Ouyang, MD*,*,
Jian Ma, MD ,
Siew Yen Ho, PhD ,
Dietmar Bänsch, MD*,
Boris Schmidt, MD*,
Sabine Ernst, MD*,
Karl-Heinz Kuck, MD*,
Shaowen Liu, MD*,
He Huang, MD*,
Min Chen, MD*,
Julian Chun, MD*,
Yunlong Xia, MD*,
Kazuhiro Satomi, MD*,
Huimin Chu, MD*,
Shu Zhang, MD and
Matthias Antz, MD*
* II. Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany
Arrhythmia Center, Fuwai Cardiovascular Hospital, Beijing, China
Department of Paediatrics, National Heart and Lung Institute and Royal Brompton Hospital, Imperial College School of Medicine, London, England
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Figure 1 Continuous recordings from tracings A to B show electrocardiogram (ECG) leads I, II, V1, V6, and intracardiac electrogram recorded from a mapping catheter at the His bundle region (RA-AS 1 to 2, RA-AS 3 to 4, RA-AS uni), a catheter in the right atrium, a catheter at the His bundle region, a catheter within the coronary sinus, and a catheter at the right ventricular apex during intravenous administration of 12 mg adenosine in a patient with induced sustained focal atrial tachycardia originating from the non-coronary aortic sinus. Note that: 1) there is the change in the tachycardia cycle length (TCL), from 431 to 485 ms, before termination during intravenous administration of 12 mg adenosine; 2) the interval from atrium to His activation (AH interval) during the tachycardia depends on the previous TCL, which results in short AH interval with previous long TCL or long AH interval with previous short TCL; and 3) the tachycardia termination occurs without sequential atrioventricular block during sinus rhythm. AS = aortic sinus; CS = coronary sinus; HBE = His bundle region; RA = right atrium; RVA = right ventricular apex.
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Figure 2 P-wave morphology on 12-lead ECG in three patients with focal atrial tachycardia (FAT) originating from the non-coronary aortic sinus.
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Figure 3 Tracings are ECG leads I, aVF, V1, and intracardiac electrogram recorded from a mapping catheter, a catheter at the HBE, a catheter within the CS, and a catheter at the right ventricular apex (RVA) in a patient with focal atrial tachycardia originating from the non-coronary AS. (A) The earliest activation in the right atrium is shown at the His bundle region (RA-AS 1 to 2, RA-AS 3 to 4, RA-AS uni). Note that the earliest activation preceding the fixed atrial electrogram recorded from the CS 1 to 2 by 56 ms and a tiny His potential at this site. The tachycardia was unsuccessfully terminated by radiofrequency (RF) delivery at this site. (B) The earliest activation in the left atrium is located at the left anteroseptal region immediately opposite the His bundle in the RA (LA-AS 1 to 2, LA-AS 3 to 4, LA-AS uni). Note that the earliest activation preceded the fixed atrial electrogram recorded from the CS 1 to 2 by 54 ms and there was no His potential at this site. The tachycardia was also unsuccessfully terminated by RF delivery at this site. (C) The successful site with an earliest RA activation is shown at the non-coronary AS (non-coro AS 1 to 2, non-coro AS 3 to 4, non-coro AS uni). Note that the earliest activation preceded the fixed atrial electrogram recorded from the CS 1 to 2 by 68 ms and there was no His potential recording at this site. LA = left atrium; other abbreviations as in Figure 1.
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Figure 4 Right (30°) and left (45°) oblique radiographic view show the mapping catheter (Map) at the successful ablation site in the AS (A,B), a multipolar catheter inside the CS, a multipolar catheter at the HBE, a catheter in the RA, and a catheter in the RV. Aortic root angiography in right (30°) and left (45°) oblique radiographic view (C,D) shows a mapping catheter in the non-coronary aortic sinus supero-posterior to sites with His bundle potential recording at distal one to four electrodes. L = left aortic sinus; N = non-coronary aortic sinus; R = right aortic sinus; other abbreviations as in Figure 1.
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Figure 5 Tracings are ECG leads I, II, V1, and intracardiac electrogram recorded from a mapping catheter, a catheter in the RA, a catheter at the HBE, a catheter within the CS, and a catheter at the RVA in a patient with focal atrial tachycardia originating from the non-coronary aortic sinus. (A) Mapping in the RA during tachycardia demonstrates that the earliest right atrial activation is found at the HBE (RA-AS 1 to 2, RA-AS 3 to 4, RA-AS uni). Note that: 1) the earliest activation preceded the fixed atrial electrogram recorded from the coronary sinus by 67 ms and a discrete His potential at this site; and 2) the amplitude change of His activation during the tachycardia indicates an unstable catheter position at the HBE. (B) Mapping in the AS demonstrates the earliest atrial activation in the non-coronary AS (non-coro AS 1 to 2, non-coro AS 3 to 4, non-coro AS uni) with the same activation time compared to the earliest right atrial activation. Note that: 1) the earliest activation preceded the fixed atrial electrogram recorded from the coronary sinus by 67 ms; and 2) no His activation is found at the successful site in the non-coronary AS. Abbreviations as in preceding figures.
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Figure 6 Tracings are ECG leads I, aVF, V1, and intracardiac electrogram recorded from a mapping catheter in the non-coronary AS (non-coro AS 1 to 2, non-coro AS 3 to 4, non-coro AS uni), a catheter at the HBE, a catheter within the CS, and a catheter at the RVA during RF delivery in a patient with FAT. Note that FAT is successfully terminated after 1.4 s during the first RF application. RF = radiofrequency; other abbreviations as in preceding figures.
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Figure 7 (a) The cardiac base is displayed to show the central location of the aortic valve and proximity of the non-coronary AS to the paraseptal region between right and left atria. (b and c) A heart specimen is sectioned in the paracoronal plane to show the rightward extent of the non-coronary AS (black arrows) and the right atrial wall (blue arrows). The green arrow indicates the membranous septum. The filled shape marks the location of the atrioventricular node; the asterisk denotes the His bundle, and the branching atrioventricular conduction bundle is represented by the blue line. (d) This simulated parasternal long axis cut through a heart specimen shows the leftward extent of the non-coronary AS (black arrows) overlying the left atrial wall (red arrows). (e) This histologic section stained with van Gieson stain corresponds to the cut shown in panel D. On the ventricular aspect there is fibrous continuity (open arrow) between aortic and mitral valve. On the atrial aspect, left atrial myocardium overlaps the fibrous continuity. Scale bars are 1 cm. LCA = left coronary artery; LV = left ventricle; MV = mitral valve; R = right coronary AS; other abbreviations as in preceding figures.
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