(Circulation. 2001;103:699.)
© 2001 American Heart Association, Inc.
Clinical Investigation and Reports |
Characterization of Reentrant Circuit in Macroreentrant Right Atrial Tachycardia After Surgical Repair of Congenital Heart Disease
Isolated Channels Between Scars Allow "Focal" Ablation
From the Cardiac Arrhythmia Research Institute, University of Oklahoma Health Sciences Center, Oklahoma City.
Correspondence to Hiroshi Nakagawa, MD, PhD, Cardiac Arrhythmia Research Institute, 1200 Everett Dr (TUH-6E 103), Oklahoma City, OK 73104. E-mail hiroshi-nakagawa{at}ouhsc.edu
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background—The purpose of this study was to characterize the circuit of macroreentrant right atrial tachycardia (MacroAT) in patients after surgical repair of congenital heart disease (SR-CHD).
Methods and
Results—Sixteen patients with atrial
tachycardia (AT) after SR-CHD were studied (atrial septal defect in 6,
tetralogy of Fallot in 4, and Fontan procedure in 6). Electroanatomic
right atrial maps were obtained during 15 MacroATs in 13 patients,
focal AT in 1 patient, and atrial pacing in 2 patients without stable
AT. A large area of low bipolar voltage (
0.5 mV) involved most of the
free wall in all patients and contained 2 to 7 dense scars or lines of
double potentials, forming 29 narrow channels (width 2.7 cm) between
scars in all but 1 patient, who had a single scar and only focal AT.
All 15 MacroATs were propagated through narrow channels. Ablation
within the channel eliminated all 15 MacroATs with 1 to 3 (median 1)
radiofrequency applications. Ablation was performed in 9 other channels
identified during MacroAT (5 patients) and in 5 channels identified
during atrial pacing (2 patients). Conduction block was obtained across
28 of 29 channels. After ablation, reproducible sustained right AT was
not induced in any patient. During follow-up (median 13.5 months), new
MacroATs, atrial fibrillation, or palpitations occurred in 3 of 16
patients.
Conclusions—MacroAT
after SR-CHD requires a large area of low voltage containing 
2 scars
forming narrow channels. Ablation within the channels eliminates
MacroAT.
Key Words: catheter ablation • heart defects, congenital • atrial flutter • Fontan procedure
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Macroreentrant right atrial tachycardia (MacroAT) is a late complication that occurs after the surgical repair of congenital heart disease.1 2 3 4 Catheter ablation has been useful in only selected patients1 2 3 4 because of the presence of multiple or unstable (unmappable) atrial tachycardias (ATs).
Two approaches have been proposed for ablation. In the first approach, an isolated diastolic atrial potential is identified during MacroAT, and entrainment pacing is used to confirm participation within the reentrant circuit.1 4 The second approach is based on the concept that MacroAT results from reentry around the atriotomy scar. A linear lesion is created between the atriotomy scar and an anatomic barrier (tricuspid annulus or inferior vena cava [IVC] or superior vena cava [SVC]).2 3 These approaches ablated at least 1 tachycardia in 73% to 93% of patients.1 2 3 However, tachycardia recurred in 33% to 53% of patients after acute success.2 3 4 We hypothesized that the high recurrence after ablation might be related to incomplete identification of all possible reentrant circuits.
The purpose of the present study was to localize all components of MacroAT reentrant circuits in patients after the surgical repair of congenital heart disease by use of an electroanatomic mapping system5 and to identify and eliminate other potential reentrant circuits that might be related to otherwise unmappable tachycardias.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
All patients referred for ablation of AT after the surgical repair of congenital heart disease were included. Patients were not excluded for multiple ATs by history or at electrophysiological study or for noninducibility of stable sustained AT. Patients with only typical atrial flutter (AFL, reentry around the tricuspid annulus) were excluded.
Electrophysiological Study
Electrophysiological study was performed with
patients under general anesthesia (propofol). Multielectrode catheters
were inserted transvenously and positioned in the coronary sinus, in
the high right atrium, around the tricuspid annulus, and (except Fontan
patients) in the His bundle region and right ventricle. Right atrial
mapping was performed during each sustained AT by use of a quadripolar
electrode catheter with 0.5- to 5- to 2-mm spacing and a 4-mm
tip electrode (Navistar, Biosense Webster). The average distance
between mapped sites was 
5 mm (2 to 4 mm in areas of
interest).
Electroanatomic Mapping System
The electroanatomic mapping system (CARTO, Biosense
Webster) has been described
previously.5 With use of a
magnetic sensor, the system displays the location of the
mapping/ablation catheter relative to the location of a reference
sensor taped to the posterior chest (accuracy 1
mm).5
A coronary sinus or right atrial electrogram was used as a
timing reference. A window of time, equal to the tachycardia cycle
length, was established around the reference activation time. The
activation time at each site was displayed in color relative to its
timing within the window (earliest, red; latest, purple). The voltage
of the bipolar atrial potential recorded at each site was also
displayed in color (lowest, red; greatest, purple). Areas with no
atrial potential distinguishable from noise (generally 0.03 mV) were
considered dense scars and were displayed in
gray.
Definition of MacroAT
MacroAT was defined as follows: (1) continuous
sequence of activation, with earliest activation (red) adjacent to
latest activation (purple), and (2) range of activation times equal to
the tachycardia cycle length.
A focal pattern of activation was defined as follows: (1) radiation in all directions from a single site of earliest activation and (2) range of activation times less than the tachycardia cycle length.
Ablation
Ablation was directed at the site of earliest
activation for focal AT and directed at isolated channels for MacroAT.
Radiofrequency (RF) current was initiated at 10 W, was increased
until the impedance decreased 3 to 5
, and was maintained until the
unipolar atrial potential recorded from the ablation electrode
decreased by 80% or split into 2 small potentials, indicating
transmural necrosis. The catheter was held stationary (70%) or was
dragged across the channel (30%).
Conduction block across the channel was verified by pacing close to the ablation line and by demonstration of marked delay and reversal in the direction of activation on the opposite side of the ablation line. Programmed stimulation was repeated to induce the same or another AT.
When AT was nonsustained, variable in activation sequence, or nonreinducible (unmappable AT), mapping was performed during atrial pacing to identify the channels between scars. Ablation was performed across as many narrow (<3.0 cm in width) channels as possible.
Postablation Management
Transesophageal echocardiography was performed within
24 hours after ablation. Patients with repair of an atrial septal
defect (ASD) or tetralogy of Fallot (ToF) received aspirin (325 mg/d)
for 6 weeks. Patients with a Fontan procedure or history of atrial
fibrillation received warfarin. The patients were discharged on no
antiarrhythmic drugs.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Study Population
The study population consisted of 16 patients (Table 1
). Six had repair of secundum ASD; 4 had correction
of ToF; and 6 had the Fontan procedure.
|
AT, present for 1 to 13 years, was paroxysmal in 10 patients and incessant in 6. Multiple ATs had been documented in 12 (75%) patients. AT was unresponsive to 2 to 6 (median 3) antiarrhythmic drugs in all patients, including amiodarone in 9 patients. Nine (56%) patients had prior unsuccessful ablation procedures for AT. Six patients had previously undergone ablation of AFL.
Electrophysiological Study
Sixty-nine ATs (1 to 7 per patient, median 5) were
present incessantly (6 ATs) or were induced by programmed stimulation
(63 ATs,
Figure 1). Four tachycardias originated from the left
atrium, and 65 originated from the right atrium. Seventeen right ATs in
14 of the 16 patients were sustained and reproducible, allowing a
complete right atrial map during tachycardia. Fifteen of 17 ATs (13 of
14 patients) exhibited a macroreentrant activation pattern, and 2 ATs
(2 patients) exhibited focal activation originating at the crista
terminalis.
|
In the remaining 2 patients (Nos. 6 and 16,
Table 1
) with unmappable AT, a right atrial map was
obtained during atrial pacing to localize potential arrhythmogenic
channels.
ASD Patients
A complete right atrial map (182 to 318 points) was
obtained during 5 ATs in 5 of 6 ASD patients (Nos. 1 to 5) and was
consistent with MacroAT in all
(Figure 2). The circuit was located within a large area of
low voltage (bipolar voltage 0.5 mV) involving the free wall and
extending to the septum (median height 7.8 cm, width 10.3 cm;
Table 2) in all patients. The low-voltage area contained
many sites exhibiting fragmented or double atrial potentials. It also
contained 2 adjacent areas with no bipolar atrial potential
distinguishable from noise (dense scars) in 2 patients
(Figures 2 and 3) or a narrow scar (line of double potentials)
adjacent to a dense scar in 3 patients
(Figures 4 and 5). The dense scars or areas of double
potentials measured 1.0 to 4.9 (median 2.4) cm in length and 0.5 to 4.4
(median 1.6) cm in width. The lower scar appeared continuous with the
IVC in all 5 patients. The upper scar was larger than the lower scar
and located at the mid free wall in 4 of 5 patients
(Figure 3). The MacroAT circuit propagated around the upper
scar and through the narrow channel between the 2 adjacent scars in all
5 patients. The channels were 0.7 to 1.6 cm in width and 0.8 to 3.4
cm in length
(Table 2).
|
|
|
|
|
All 5 MacroATs were terminated by 1 to 3 (median 2)
stationary
(Figures 2 and 3) or dragging
(Figure 4) RF applications applied within an isolated
channel. After ablation of the single channel, the original AT was not
induced in any of the patients. No other AT was induced in 3 of 5
patients (Nos. 1, 2, and 4). In patient 3, 1 episode of another AT was
induced. This tachycardia could not be reinduced, preventing mapping
and ablation. Two left ATs were also induced in this patient. Neither
left atrial mapping nor ablation was attempted. In patient 5, 6 other
ATs were induced that were nonsustained or not reinduced. After
ablation across 2 other channels selected from the initial map
(Figures 4 and 5A), no AT was induced.
In the remaining patient (No. 6), entrainment pacing
performed before completion of the map terminated the MacroAT. The
original tachycardia could not be reinduced. Stimulation induced
multiple episodes of 3 other nonsustained ATs. A map was then obtained
during atrial pacing, revealing a large area of low voltage containing
2 dense scars forming a channel 1.5 cm in width
(Figure 5A). Ablation produced block across the channel. No
AT was induced after ablation.
Eight channels were targeted in the 6 ASD patients. Block
was confirmed in 7 patients and not tested in 1
(Table 2).
The septum did not participate in the circuit in any of the
5 mapped MacroATs. Although reduced, the septal voltage was greater
than the free wall voltage in all 6 patients
(Figure 4). The septum contained a small dense scar or double
potentials in only 2 patients (Nos. 3 and 5). The closest area of block
to these small scars was 4.4 and 3.7 cm. These wide channels were not
associated with MacroAT, and ablation was not
attempted.
ToF Patients
A map (175 to 223 points) was obtained during sustained
AT in all 4 ToF patients. Three (Nos. 7 to 9) had macroreentry confined
to the free wall within a large area of low voltage
(Table 2), containing 2 dense scars or a dense scar and a
line of double potentials
(Figure 5B). The lower scar was continuous with the IVC in 2
patients, and there was a line of double potentials (block) between the
lower scar and IVC in 1 patient
(Figure 6). In all 3 patients, reentry was propagated through
the channel (0.7 to 1.1 cm wide) and around the upper scar. Only 1 to 3
RF applications terminated tachycardia, produced block across the
channels, and prevented reinduction of any sustained AT.
|
The fourth patient (No. 10) had only focal AT (crista terminalis). One RF application eliminated the AT. The voltage map showed a narrower area of low voltage (width 3.2 cm), containing a single scar extending to the IVC (no channel).
Fontan Patients
In the 6 Fontan patients, maps containing 257 to 419
(median 321) points were obtained during 2 MacroATs (2 patients),
during 1 MacroAT (3 patients), and during atrial pacing (1 patient).
The maps demonstrated very large right atria with large areas of low
voltage involving the free wall and septum, containing 3 to 7 (median
5.5) dense scars or lines of double potentials
(Table 2). The size and location of the scars varied among
patients, resulting in different reentrant circuits
(Figure 5C).
In 2 patients (Nos. 11 and 14), the scars were continuous
with SVC or IVC, producing reentry around the right atrium in the
transverse plane
(Figure 7). The other 4 patients had 3 to 6 channels and 3 to
7 MacroATs. All channels were identified in the first map obtained
either during a tachycardia (patients 12, 13, and 15) or atrial pacing
(patient 16). For example, in patient 12, the first map obtained during
a MacroAT showed a small circuit (2-cm diameter) incorporating 2
channels plus a third uninvolved channel
(Figure 8). The voltage throughout the circuit was extremely
low (0.04 to 0.06 mV), which may explain the long cycle length (435
ms). A single stationary RF application within 1 channel terminated the
tachycardia. One additional application was delivered within the same
channel (RF2,
Figure 8B). Three applications were delivered across the
second channel, guided by the initial map (RF3 to RF5). The third
channel was subsequently shown to produce another MacroAT, which was
terminated by a single linear (1.0-cm length) RF application within the
channel (RF6), followed by an additional application (RF7).
|
|
At least 6 channels were identified from a map (367 points)
obtained during atrial pacing in patient 16, who had multiple ATs that
were unmappable because of the frequently changing activation sequence.
Four of 6 channels were selected for ablation
(Figure 5C). Block was obtained across 3 of the 4 channels.
Block was not obtained across the fourth channel with the highest
voltage (1.48 mV), consistent with thicker atrial
myocardium.
Block was obtained across 19 of 20 channels in the 6 Fontan
patients
(Figure 9, Table 2). After ablation, only 6 of 33 ATs were induced in
3 of 6 patients. These tachycardias were nonsustained (3 ATs), left
atrial (2 ATs), or nonreproducible (1 AT).
|
Entrainment Pacing
Entrainment pacing was performed in the first 3 ASD
patients, 2 ToF patients, and 1 Fontan patient. Entrainment confirmed
the sites suspected to be inside or outside the reentrant circuit on
the basis of the activation map
(Figures 2, 3, 6, and 7). Many sites within the circuit, but
outside the isolated channel ("outer loop" site), exhibited a
diastolic potential, entrainment with concealed fusion (same P wave and
activation sequence), and a postpacing interval equal to the
tachycardia cycle length (PPI=TCL). Ablation at one such site failed to
terminate tachycardia, whereas 1 application of RF current delivered
within the channel (identified from the activation map) terminated the
tachycardia, even though pacing at that site failed to capture.
(Figure 3).
Because entrainment provided only confirmatory information and could terminate the tachycardia before ablation, entrainment was not used in the last 9 patients. The number of RF applications required to terminate MacroAT was not different between the groups using and not using entrainment, 1 to 3 (median 1.5) versus 1 to 3 (median 1) applications.
Characteristics of Channel Potentials
The timing of the atrial potential at the 15 ablation
sites terminating MacroAT was distributed throughout the tachycardia
cycle length
(Figure 10). The electrogram exhibited single (6 sites),
double (5 sites), or fragmented (4 sites) atrial potentials. The
bipolar atrial potential amplitude ranged from 0.05 to 0.41 mV. The
amplitude was extremely low (0.1 mV), mimicking dense scar, at 7 of
the 15 sites
(Figure 8C).
|
Ablation of AFL
AFL was also ablated in 12 of 16 patients, 7 in this
procedure and 5 in a prior procedure.
Follow-Up
The 16 patients were followed up for 1 to 29 (median
13.5) months after ablation. Fifteen received no antiarrhythmic drug.
Patient 1 eventually received sotalol to suppress ventricular
tachycardia. Sotalol has previously failed to prevent
MacroAT.
All 16 patients have had a significant improvement in
symptoms. Atrial tachyarrhythmia recurred in 3 (19%) of 16 patients.
One ASD patient (No. 3) had 3 episodes of AT (lasting 6 hours) over 7
months. At repeat study, a new MacroAT with a longer cycle length (330
versus 208 ms) was induced. The map demonstrated reentry around a large
scar (formed by fusion of the original upper and lower scars) and
through a narrow channel between the fused scar and IVC
(Figure 5A, patient 3, dotted line). The conduction time
through the channel was 155 ms, simulating block during the first
ablation procedure. Tachycardia was eliminated by a single RF
application within the new channel. Mapping during atrial pacing after
ablation confirmed block across the new and previous
channels.
One Fontan patient (No. 12) had a single episode of atrial fibrillation 12.5 months after ablation. Electrophysiological study failed to induce any of the original ATs. Mapping confirmed block across the 3 original channels. Programmed stimulation induced a focal AT originating in the posterior right atrium, eliminated by 2 RF applications.
Another Fontan patient (No. 13) had a single episode of palpitations lasting 15 minutes and several other episodes of palpitations lasting <15 seconds. None of the episodes were recorded.
Complications
There were no
complications.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Substrate for MacroAT
The entire reentrant circuit was identified in the 15 sustained reproducible MacroATs. All circuits were located within a large area of low voltage (depressed conduction) containing a narrow channel (
2.7 cm in width) between 2 close dense or thin scars (lines
of block). The lines of block (double potentials) during tachycardia
were also recorded during atrial pacing (long cycle length) after
ablation, suggesting fixed anatomic block rather than functional block.
Similarly, areas with no atrial potential during tachycardia exhibited
no atrial potential during pacing. The arrhythmogenic substrate was found in the free wall and not the septum, even in patients with ASD closure. The cause of the large area of low voltage ("atrial myopathy") is unclear. Possible explanations include interruption of arterial supply and insufficient protection during cardioplegia. The multiple dense scars may result from the atriotomy, venous cannulation sites, conduit sites, and other surgical trauma.
The single patient with only focal AT had a narrower area of low voltage and a single dense scar extending to IVC, with no channel through the scar (no channel–no macroreentry).
Focal Ablation Within an Isolated
Channel
Each MacroAT used at least 1 narrow channel, allowing a
single point or very short linear (focal) ablation. The 15 mapped
MacroATs were terminated by 1 to 3 (median 1) stationary or short
dragging RF applications delivered within an isolated
channel.
Only 1 isolated channel was identified in 7 of 9 ASD and ToF patients. In contrast, 5 of 6 Fontan patients had multiple channels and macroreentrant circuits. Because all channels could be identified from a single high-density map (2- to 5-mm spacing), the strategy used in later patients was to obtain 1 complete map during a stable MacroAT. One channel was ablated, terminating the tachycardia. Guided by the initial map, as many other channels as possible were ablated before attempting to reinduce tachycardia. This approach reduced the number of maps required. The ability to identify the channels from a map during atrial pacing allowed the ablation of multiple channels in 2 patients with unmappable ATs. The lower success rate for ablation in Fontan patients in previous studies may relate to the inability to identify all of the channels by use of conventional mapping techniques.1 2 3 4
The atrial potential at 7 of the 15 ablation sites
terminating MacroAT was extremely small (0.1 mV), mimicking dense
scar
(Figures 8 and 10). In the present study, the maps included
every distinguishable bipolar potential. Many of the channels between 2
scars would have been obscured (displayed as a single scar) if the scar
had been defined by an arbitrary voltage criterion (ie, 0.1
mV).
The combination of a diastolic potential and
entrainment pacing showing concealed fusion with PPI=TCL has been
considered to identify a "protected isthmus" within the circuit
(ideal ablation
site).1 2 In the
present study, potentials within channels occurred throughout the
atrial cycle, not just in diastole. In addition, because most of the
cycle length involved conduction in broad low-voltage areas, many sites
outside of channels exhibited diastolic potentials and concealed
entrainment (because the paced impulse exited the low-voltage area in
the same region) with PPI=TCL
(Figure 3). Neither electrogram morphology, timing, nor
entrainment differentiated between sites within or outside a narrow
channel. Entrainment pacing may also terminate or change the
tachycardia and therefore was not helpful in the presence of a
high-density map.
After ablation of the channels, reproducible sustained right AT was not induced by programmed stimulation in any of the 15 patients. This compares favorably with the 73% to 93% acute success rate (defined as elimination of at least 1 AT) with the use of conventional catheter mapping techniques.1 2 3 More important, confirmed sustained MacroAT recurred during follow-up in only 1 patient, in whom a slowly conducting channel was initially mistaken as a block. In previous studies using conventional mapping techniques, AT recurred in 33% to 53% of patients with acute success.2 3 4
AT has not recurred in either of the 2 patients in whom ablation was performed in channels identified from a map during atrial pacing, suggesting that a high-resolution map during atrial pacing may be as useful as a map during MacroAT.
Limitations of the Study
The principal limitation of the present study was the
time required to obtain high-density maps by use of this point-by-point
technique. This limitation is mitigated somewhat by the ability to
identify all channels from a single map during 1 tachycardia or
pacing.
|
Footnotes |
|---|
Drs Nakagawa and Jackman serve as consultants to Biosense Webster.
Received July 19, 2000; revision received September 22, 2000; accepted September 26, 2000.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1. Triedman JK, Saul P, Weindling SN, et al. Radiofrequency ablation of intra-atrial reentrant tachycardia after surgical palliation of congenital heart disease. Circulation. 1995;91:707–714.
2.
Kalman JM, VanHare
GF, Olgin JE, et L. Ablation of "incisional" reentrant atrial
tachycardia complication surgery for congenital heart disease.
Circulation. 1996;93:502–512.
3. Baker BM, Lindsay BD, Bromberg B, et al. Catheter ablation of intraatrial reentrant tachycardias resulting from previous atrial surgery: location and transecting the critical isthmus. J Am Coll Cardiol. 1996;28:411–417.[Abstract]
4. Triedman JK, Bergau FD, Saul P, et al. Efficacy of radiofrequency ablation for control of intraatrial reentrant tachycardia in patients with congenital heart disease. J Am Coll Cardiol. 1997;30:1032–1038.[Abstract]
5. Ben-Haim SA, Osadchy D, Schuster I, et al. Nonfluoroscopic, in vivo navigation and mapping technology. Nat Med. 1996;2:1393–1395. [Medline] [Order article via Infotrieve]
This article has been cited by other articles:
 |
|
 |
|
  N. M.S. de Groot, P. Lukac, N. A. Blom, J. P. van Kuijk, A. K. Pedersen, P. S. Hansen, E. Delacretaz, and M. J. Schalij Long-Term Outcome of Ablative Therapy of Postoperative Supraventricular Tachycardias in Patients With Univentricular Heart: A European Multicenter Study Circ Arrhythm Electrophysiol, June 1, 2009; 2(3): 242 - 248. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Peichl, J. Kautzner, and R. Gebauer Ablation of atrial tachycardias after correction of complex congenital heart diseases: utility of intracardiac echocardiography Europace, January 1, 2009; 11(1): 48 - 53. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J.#x.;n. Farré, H. J.J. Wellens, J.#x. M. Rubio, and J. Benezet CHAPTER 28 Supraventricular Tachycardias ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. A. Warnes, R. G. Williams, T. M. Bashore, J. S. Child, H. M. Connolly, J. A. Dearani, P. del Nido, J. W. Fasules, T. P. Graham Jr, Z. M. Hijazi, et al. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease) Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons J. Am. Coll. Cardiol., December 2, 2008; 52(23): e143 - e263. [Full Text] [PDF]
|
|
|
|
 |
|
 C. A. Warnes, R. G. Williams, T. M. Bashore, J. S. Child, H. M. Connolly, J. A. Dearani, P. del Nido, J. W. Fasules, T. P. Graham Jr, Z. M. Hijazi, et al. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease): Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Circulation, December 2, 2008; 118(23): e714 - e833. [Full Text] [PDF]
|
|
|
|
|
|
K. Yokoyama, H. Nakagawa, D. C. Shah, H. Lambert, G. Leo, N. Aeby, A. Ikeda, J. V. Pitha, T. Sharma, R. Lazzara, et al. Novel Contact Force Sensor Incorporated in Irrigated Radiofrequency Ablation Catheter Predicts Lesion Size and Incidence of Steam Pop and Thrombus Circ Arrhythm Electrophysiol, December 1, 2008; 1(5): 354 - 362. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Knackstedt, P. Schauerte, and P. Kirchhof Electro-anatomic mapping systems in arrhythmias Europace, November 1, 2008; 10(suppl_3): iii28 - iii34. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. M. Patel, A. d'Avila, P. Neuzil, S. J. Kim, MSEE, T. Mela, J. P. Singh, J. N. Ruskin, and V. Y. Reddy Atrial Tachycardia After Ablation of Persistent Atrial Fibrillation: Identification of the Critical Isthmus With a Combination of Multielectrode Activation Mapping and Targeted Entrainment Mapping Circ Arrhythm Electrophysiol, April 1, 2008; 1(1): 14 - 22. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. E. Eckart and L. M. Epstein Interventional Therapy for Atrial and Ventricular Arrhythmias Card. Surg. Adult, January 1, 2008; 3(2008): 1357 - 1374. [Full Text]
|
|
|
|
|
|
G. F. Van Hare Substrate Mapping and Catheter Ablation of Ventricular Tachycardia after Right Ventriculotomy Circulation, November 13, 2007; 116(20): 2236 - 2237. [Full Text] [PDF]
|
|
|
|
|
|
E. P. Walsh Interventional Electrophysiology in Patients With Congenital Heart Disease Circulation, June 26, 2007; 115(25): 3224 - 3234. [Full Text] [PDF]
|
|
|
|
 |
|
 P. Lukac, V. E. Hjortdal, A. K. Pedersen, P. T. Mortensen, H. K. Jensen, and P. S. Hansen Prevention of Atrial Flutter With Cryoablation May Be Proarrhythmogenic Ann. Thorac. Surg., May 1, 2007; 83(5): 1717 - 1723. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Kanter The Fontan Right Atrium--In Context Circulation, April 3, 2007; 115(13): 1698 - 1700. [Full Text] [PDF]
|
|
|
|
|
|
D. J. Abrams, M. J. Earley, S. C. Sporton, P. M. Kistler, M. A. Gatzoulis, M. J. Mullen, J. A. Till, S. Cullen, F. Walker, M. D. Lowe, et al. Comparison of Noncontact and Electroanatomic Mapping to Identify Scar and Arrhythmia Late After the Fontan Procedure Circulation, April 3, 2007; 115(13): 1738 - 1746. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. P. Walsh and F. Cecchin Arrhythmias in Adult Patients With Congenital Heart Disease Circulation, January 30, 2007; 115(4): 534 - 545. [Full Text] [PDF]
|
|
|
|
|
|
K. Yokoyama, H. Nakagawa, F. H.M. Wittkampf, J. V. Pitha, R. Lazzara, and W. M. Jackman Comparison of Electrode Cooling Between Internal and Open Irrigation in Radiofrequency Ablation Lesion Depth and Incidence of Thrombus and Steam Pop Circulation, January 3, 2006; 113(1): 11 - 19. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Sanders, M. Hocini, P. Jais, L.-F. Hsu, Y. Takahashi, M. Rotter, C. Scavee, J.-L. Pasquie, F. Sacher, T. Rostock, et al. Characterization of Focal Atrial Tachycardia Using High-Density Mapping J. Am. Coll. Cardiol., December 6, 2005; 46(11): 2088 - 2099. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Kilicaslan, A. Verma, H. Yamaji, N. F. Marrouche, O. Wazni, J. E. Cummings, S. Hao, M. W. Andrews, S. Beheiry, A. Abdul-Karim, et al. The need for atrial flutter ablation following pulmonary vein antrum isolation in patients with and without previous cardiac surgery J. Am. Coll. Cardiol., March 1, 2005; 45(5): 690 - 696. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Nabar, C. Timmermans, A. Medeiros, K. Polymeropoulous, H.J.G.M. Crijns, and L.M. Rodriguez Radiofrequency ablation of atrial arrhythmias after previous open-heart surgery Europace, January 1, 2005; 7(1): 40 - 49. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C.-T. Tai, T.-Y. Liu, P.-C. Lee, Y.-J. Lin, M.-S. Chang, and S.-A. Chen Non-contact mapping to guide radiofrequency ablation of atypical right atrial flutter J. Am. Coll. Cardiol., September 1, 2004; 44(5): 1080 - 1086. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Verma, N. F. Marrouche, N. Seshadri, R. A. Schweikert, M. Bhargava, J. D. Burkhardt, F. Kilicaslan, J. Cummings, W. Saliba, and A. Natale Importance of ablating all potential right atrial flutter circuits in postcardiac surgery patients J. Am. Coll. Cardiol., July 21, 2004; 44(2): 409 - 414. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. M.S. de Groot, M. J. Schalij, K. Zeppenfeld, N. A. Blom, E. T. Van der Velde, and E. E. Van der Wall Voltage and Activation Mapping: How the Recording Technique Affects the Outcome of Catheter Ablation Procedures in Patients With Congenital Heart Disease Circulation, October 28, 2003; 108(17): 2099 - 2106. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Committee Members, C. Blomstrom-Lundqvist, M. M. Scheinman, E. M. Aliot, J. S. Alpert, H. Calkins, A. J. Camm, W. B. Campbell, D. E. Haines, K. H. Kuck, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias --executive summary: a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) Developed in Collaboration with NASPE-Heart Rhythm Society J. Am. Coll. Cardiol., October 15, 2003; 42(8): 1493 - 1531. [Full Text] [PDF]
|
|
|
|
|
|
C. Blomstrom-Lundqvist, M. M. Scheinman, E. M. Aliot, J. S. Alpert, H. Calkins, A. J. Camm, W. B. Campbell, D. E. Haines, K. H. Kuck, B. B. Lerman, et al. ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias*--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias) Circulation, October 14, 2003; 108(15): 1871 - 1909. [Full Text] [PDF]
|
|
|
|
 |
|
 Committee Members, C. Blomstrom-Lundqvist, M. M Scheinman, E. M Aliot, J. S Alpert, H. Calkins, A.J. Camm, W.B. Campbell, D. E Haines, K. H Kuck, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary: A Report of the American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines(Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias)Developed in collaboration with NASPE-Heart Rhythm Society Eur. Heart J., October 2, 2003; 24(20): 1857 - 1897. [Full Text] [PDF]
|
|
|
|
 |
|
 Y. Ishii, T. Nitta, S.-i. Sakamoto, S. Tanaka, and G. Asano Incisional atrial reentrant tachycardia: experimental study on the conduction property through the isthmus J. Thorac. Cardiovasc. Surg., July 1, 2003; 126(1): 254 - 262. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. D. Satti and L. M. Epstein Cardiologic Interventional Therapy for Atrial and Ventricular Arrhythmias Card. Surg. Adult, January 1, 2003; 2(2003): 1253 - 1270. [Full Text]
|
|
|
|
|
|
H. Nakagawa and W. M. Jackman Catheter ablation of macroreentrant atrial tachycardia in patients following atriotomy Eur. Heart J., October 2, 2002; 23(20): 1566 - 1568. [Full Text] [PDF]
|
|
|
|
|
|
W. Anne, H. van Rensburg, J. Adams, H. Ector, F. Van de Werf, and H. Heidbuchel Ablation of post-surgical intra-atrial reentrant tachycardia. Predilection target sites and mapping approach Eur. Heart J., October 2, 2002; 23(20): 1609 - 1616. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. M. Markowitz, R. F. Brodman, K. M. Stein, S. Mittal, D. J. Slotwiner, S. Iwai, M. K. Das, and B. B. Lerman Lesional tachycardias related to mitral valve surgery J. Am. Coll. Cardiol., June 19, 2002; 39(12): 1973 - 1983. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. A Friedman Novel mapping techniques for cardiac electrophysiology Heart, June 1, 2002; 87(6): 575 - 582. [Full Text] [PDF]
|
|
|
|
|
|
J. B. Morton, P. Sanders, V. Deen, J. K. Vohra, and J. M. Kalman Sensitivity and specificity of concealed entrainment for the identification of a critical isthmus in the atrium: relationship to rate, anatomic location and antidromic penetration J. Am. Coll. Cardiol., March 6, 2002; 39(5): 896 - 906. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Ott Dual-loop intra-atrial re-entry tachycardia in a patient with ischaemic cardiomyopathy Europace, January 1, 2002; 4(2): 207 - 210. [Abstract] [PDF]
|
|
|
|
|
|
Y. Yang, J. Cheng, A. Bochoeyer, M. H. Hamdan, R. C. Kowal, R. Page, R. J. Lee, P. R. Steiner, L. A. Saxon, M. D. Lesh, et al. Atypical Right Atrial Flutter Patterns Circulation, June 26, 2001; 103(25): 3092 - 3098. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Ouyang, S. Ernst, T. Vogtmann, M. Goya, M. Volkmer, A. Schaumann, D. Bansch, M. Antz, and K.-H. Kuck Characterization of Reentrant Circuits in Left Atrial Macroreentrant Tachycardia: Critical Isthmus Block Can Prevent Atrial Tachycardia Recurrence Circulation, April 23, 2002; 105(16): 1934 - 1942. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||