Atrial Tachycardia After Circumferential Pulmonary Vein Ablation of Atrial FibrillationMechanistic Insights, Results of Catheter Ablation, and Risk Factors for Recurrence
Sanders Chae, MD,
Hakan Oral, MD, FACC,
Eric Good, DO, FACC,
Sujoya Dey, MD,
Alan Wimmer, MD,
Thomas Crawford, MD,
Darryl Wells, MD,
Jean-Francois Sarrazin, MD,
Nagib Chalfoun, MD,
Michael Kuhne, MD,
Jackie Fortino, RN,
Elizabeth Huether, CVT,
Tammy Lemerand, CVT,
Frank Pelosi, MD, FACC,
Frank Bogun, MD, FACC,
Fred Morady, MD, FACC and
Aman Chugh, MD, FACC*
Division of Cardiology, University of Michigan Hospitals, Ann Arbor, Michigan
View larger version (64K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1 Mechanism and Distribution of Re-Entrant Circuits
(A) Pie chart showing the frequency and location of macro–re-entrant atrial tachycardias (ATs). (B) Pie chart showing the frequency and location of small re-entrant ATs. AW = anterior wall; CS = coronary sinus; CTI = cavotricuspid isthmus; LSPV = around the left superior pulmonary vein; MI = mitral isthmus; PW = posterior wall; RI = right inferior; RS = right superior.
|
|
View larger version (48K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2 Example of a Gap-Related Septal AT
(A) Electroanatomical map of the left atrium from a patient with paroxysmal atrial fibrillation, in an anteroposterior (AP) projection. The red circles represent sites of radiofrequency energy delivery. The open circles indicate areas at which radiofrequency energy with an 8-mm-tip catheter could not be applied for more than a few seconds because of an abrupt decrease in the delivered power. (B) An activation map performed several months later during a septal atrial tachycardia (AT) in the same patient, in an AP view with cranial angulation. There is a figure-of-8 activation pattern that is stabilized superiorly by a corridor of widely split (90 ms) double potentials (red arrows) related to prior ablation at the roof, by the mitral annulus, and by the right-sided pulmonary veins (PV). The tachycardia is likely utilizing gaps in the incomplete ablation line shown in (A). Gold circles represent sites at which the post-pacing interval matched the tachycardia cycle length. Linear ablation (dashed circles) from the mitral annulus to the right-sided pulmonary veins resulted in prolongation of the tachycardia cycle length but was unsuccessful in terminating the tachycardia. Entrainment mapping showed that the right atrial septum also was part of the circuit; however, ablation at this site also failed to terminate the tachycardia. L = left; R = right.
|
|
View larger version (84K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3 Example of a Multiple-Loop AT Circuit
(A) Activation map of the left atrium (LA) in a posteroanterior (PA) view. There is counterclockwise activation along the posterior wall. The pink tags show the course of the esophagus. (B) Activation map of the LA in a shallow left anterior oblique view. There are 2 more loops, one with clockwise activation along the anterior wall (white loop) and another with clockwise activation (yellow loop) around the mitral valve (MV). The latter is consistent with an epicardial mitral isthmus circuit utilizing the coronary sinus (CS). The dashed brown portion of the mitral-isthmus loop refers to activation along the posterior wall. The loops along the anterior and posterior walls converge at the roof. The ostial aspect of the CS was also shown to be part of the circuit by entrainment mapping (Fig. 4), making it a quadruple-loop circuit. The mitral isthmus loop was targeted first, and ablation was commenced at the distal CS because there were no appreciable electrograms at the endocardial aspect of the isthmus. See Figures 4 and 5 for further details. Note the presence of scar (gray circles), especially at the mitral isthmus. AT = atrial tachycardia.
|
|
View larger version (18K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4 Entrainment Mapping in the Same Patient as in Figure 3
(A) The post-pacing interval (PPI) from the ostial aspect of the coronary sinus (CS) is 250 ms, matching the tachycardia cycle length. (B) Entrainment mapping from the distal CS also shows a perfect return cycle. (C) Entrainment mapping from the distal CS after radiofrequency ablation (RFA). Despite a lack of change in the P-wave morphology or the tachycardia cycle length, a long PPI implies that the mitral/distal CS portion of the AT circuit has been eliminated. Also shown are electrocardiographic leads II, V1, and V5, and bipolar electrograms recorded by catheters placed in the left atrium (LAd and LAp) and right atrium (RAd and RAp). Os = ostium.
|
|
View larger version (11K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5 Effect of Radiofrequency Ablation in the Same Patient as in Figures 3 and 4
(A) Radiofrequency energy delivery at the LA roof slows the tachycardia cycle length from 250 to 275 ms. Concomitantly, the P-wave morphology abruptly changes from upright to biphasic in lead V1
(arrows), indicating that the 2 loops converging at the roof have been eliminated. (B) Effect of radiofrequency energy delivery in the proximal CS. After entrainment mapping showed that the PPI at the proximal CS was still the same as the tachycardia cycle length, ablation at this site eliminated the last loop, resulting in sinus rhythm. There were no inducible tachycardias thereafter. Abl = ablation; other abbreviations as in Figure 4.
|
|
|
