Circulation, Vol 86, 1233-1240, Copyright © 1992 by American Heart Association
GK Feld, RP Fleck, PS Chen, K Boyce, TD Bahnson, JB Stein, CM Calisi and M Ibarra
BACKGROUND. Recent studies of human type 1 atrial flutter demonstrated
reentry in the right atrium and an area of slow conduction in the low
posteroseptal right atrium. Direct-current catheter ablation of this area
has been only moderately successful in preventing recurrence. Therefore, we
performed endocardial activation mapping and entrainment pace mapping
during atrial flutter to determine the critical site for radiofrequency
ablation of this arrhythmia. METHODS AND RESULTS. Twelve consecutive
patients (seven men and five women; age, 21-73 years) with type 1 atrial
flutter (mean cycle length, 253 +/- 39 msec) underwent right atrial
endocardial activation and entrainment pace mapping using standard
transvenous catheter techniques to localize the atrial flutter reentrant
circuit, the area of slow conduction, and the exit site from the area of
slow conduction. Upon identifying appropriate sites, radiofrequency energy
(16-29 W) was applied via a 4-mm tipped catheter. Activation mapping of
atrial flutter revealed a counterclockwise reentrant wave front originating
just inferior or posterior to the coronary sinus ostium, proceeding
superiorly in the atrial septum to the right atrial free wall, then
inferiorly toward the tricuspid annulus and finally medially between the
inferior vena cava and the tricuspid annulus, where low-amplitude
fragmented electrical activity was noted. Entrainment pace mapping from
this area produced an exact P wave match to atrial flutter on 12-lead ECG
with a long (greater than 40 msec) stimulus-to-P interval indicating slow
conduction, whereas pacing just inferior or posterior to the coronary sinus
ostium produced an exact P wave match with a short stimulus-to-P interval
(less than 40 msec), presumably identifying the exit site from the area of
slow conduction. Radiofrequency energy (one to 14 applications) was
effective in terminating and preventing reinduction of atrial flutter in 10
patients. In two patients, atrial flutter was not terminated during
radiofrequency energy application but during subsequent pacing attempts.
Sites where ablation was successful, located just inferior or posterior to
the coronary sinus ostium, were characterized by discrete electrograms with
activation times of -20 to -50 msec before P wave onset and exact
entrainment pace maps with a stimulus-to-P interval of 20 to 40 msec,
consistent with the exit site from the area of slow conduction. Follow-up
(mean, 16 +/- 9 weeks; range, 2-31 weeks) revealed recurrence of the
original atrial flutter in two patients, one of whom underwent repeat
ablation without further recurrence, self- limited infrequent recurrence of
a new atrial flutter or atrial fibrillation in three suppressed by
beta-blocker or digoxin, and no recurrence in seven. CONCLUSIONS. 1)
Radiofrequency energy applied to a critical area in the atrial flutter
reentrant circuit, inferior or posterior to the coronary sinus ostium, will
terminate and prevent arrhythmia reinduction. 2) Long-term follow-up in a
larger series of patients will be required to confirm efficacy of this
technique, although short-term results look promising.
ARTICLES
Radiofrequency catheter ablation for the treatment of human type 1 atrial flutter. Identification of a critical zone in the reentrant circuit by endocardial mapping techniques
Department of Medicine, University of California, School of Medicine, San Diego 92103-8411.
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H. Nakagawa, R. Lazzara, T. Khastgir, K. J. Beckman, J. H. McClelland, S. Imai, J. V. Pitha, A. E. Becker, M. Arruda, M. D. Gonzalez, et al. Role of the Tricuspid Annulus and the Eustachian Valve/Ridge on Atrial Flutter: Relevance to Catheter Ablation of the Septal Isthmus and a New Technique for Rapid Identification of Ablation Success Circulation, August 1, 1996; 94(3): 407 - 424. [Abstract] [Full Text]
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M. D. Rodefeld, B. I. Bromberg, R. B. Schuessler, J. P. Boineau, J. L. Cox, and C. B. Huddleston ATRIAL FLUTTER AFTER LATERAL TUNNEL CONSTRUCTION IN THE MODIFIED FONTAN OPERATION: A CANINE MODEL J. Thorac. Cardiovasc. Surg., March 1, 1996; 111(3): 514 - 526. [Abstract] [Full Text]
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J. M. Kalman, G. F. VanHare, J. E. Olgin, L. A. Saxon, S. I. Stark, and M. D. Lesh Ablation of `Incisional' Reentrant Atrial Tachycardia Complicating Surgery for Congenital Heart Disease : Use of Entrainment to Define a Critical Isthmus of Conduction Circulation, February 1, 1996; 93(3): 502 - 512. [Abstract] [Full Text]
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B. Cauchemez, M. Haissaguerre, B. Fischer, O. Thomas, J. Clementy, and P. Coumel Electrophysiological Effects of Catheter Ablation of Inferior Vena Cava–Tricuspid Annulus Isthmus in Common Atrial Flutter Circulation, January 15, 1996; 93(2): 284 - 294. [Abstract] [Full Text]
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T. Yamashita, T. Nakajima, H. Hazama, E. Hamada, Y. Murakawa, K. Sawada, and M. Omata Regional Differences in Transient Outward Current Density and Inhomogeneities of Repolarization in Rabbit Right Atrium Circulation, November 15, 1995; 92(10): 3061 - 3069. [Abstract] [Full Text]
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J. E. Olgin, J. M. Kalman, A. P. Fitzpatrick, and M. D. Lesh Role of Right Atrial Endocardial Structures as Barriers to Conduction During Human Type I Atrial Flutter : Activation and Entrainment Mapping Guided by Intracardiac Echocardiography Circulation, October 1, 1995; 92(7): 1839 - 1848. [Abstract] [Full Text]
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T. Tabuchi, K. Okumura, T. Matsunaga, R. Tsunoda, M. Jougasaki, and H. Yasue Linear Ablation of the Isthmus Between the Inferior Vena Cava and Tricuspid Annulus for the Treatment of Atrial Flutter : A Study in the Canine Atrial Flutter Model Circulation, September 1, 1995; 92(5): 1312 - 1319. [Abstract] [Full Text]
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F. Philippon, V. J. Plumb, A. E. Epstein, and G. N. Kay The Risk of Atrial Fibrillation Following Radiofrequency Catheter Ablation of Atrial Flutter Circulation, August 1, 1995; 92(3): 430 - 435. [Abstract] [Full Text]
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J. K. Triedman, J. P. Saul, S. N. Weindling, and E. P. Walsh Radiofrequency Ablation of Intra-Atrial Reentrant Tachycardia After Surgical Palliation of Congenital Heart Disease Circulation, February 1, 1995; 91(3): 707 - 714. [Abstract] [Full Text]
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 A. B. Wagshal, L. A. Pires, and S. K. Stephen Management of Cardiac Arrhythmias With Radiofrequency Catheter Ablation Arch Intern Med, January 23, 1995; 155(2): 137 - 147. [Abstract] [PDF]
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