(Circulation. 1999;99:2771-2778.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Rate-Dependent Conduction Block of the Crista Terminalis in Patients With Typical Atrial Flutter
Influence on Evaluation of Cavotricuspid Isthmus Conduction Block
From the Department of Cardiology, Hospital General Universitario Gregorio Marañón (A.A., J.A., J.V., J.L.M.S., N.P.-C., S.G., M.O., J.L.D.), Madrid, Spain, and Hospital de Basurto (J.M.A., J.M.O.), Bilbao, Spain.
Correspondence to Angel Arenal, Laboratorio de Electrofisiología, Departamento de Cardiología, Hospital General Universitario Gregorio Marañón, C/Dr Esquerdo 46, 28007 Madrid, Spain. E-mail arenal{at}doymanet.es
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background—The crista terminalis (CT) has been identified as the posterior boundary of typical atrial flutter (AFL) in the lateral wall (LW) of the right atrium (RA). To study conduction properties across the CT, rapid pacing was performed at both sides of the CT after bidirectional conduction block was achieved in the cavotricuspid isthmus by radiofrequency catheter ablation.
Methods and Results—In 22 patients (aged 61±7 years) with AFL (cycle length, 234±23 ms), CT was identified during AFL by double electrograms recorded between the LW and posterior wall (PW). After the ablation procedure, decremental pacing trains were delivered from 600 ms to 2-to-1 local capture at the LW and PW or coronary sinus ostium (CSO). At least 5 bipolar electrograms were recorded along the CT from the high to the low atrium next to the inferior vena cava. No double electrograms were recorded during sinus rhythm in that area. Complete transversal conduction block all along the CT (detected by the appearance of double electrograms at all recording sites and craniocaudal activation sequence on the side opposite to the pacing site) was observed in all patients during pacing from the PW or CSO (cycle length, 334±136 ms), but it was fixed in only 4 patients. During pacing from the LW, complete block appeared at a shorter pacing cycle length (281±125 ms; P<0.01) and was fixed in 2 patients. In 3 patients, complete block was not achieved.
Conclusions—These data suggest the presence of rate-dependent transversal conduction block at the crista terminalis in patients with typical AFL. Block is usually observed at longer pacing cycle lengths with PW pacing than with LW pacing. This difference may be a critical determinant of the counterclockwise rotation of typical AFL.
Key Words: atrial flutter • atrium • electrophysiology • conduction
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Typical atrial flutter (AFL) is a macroreentrant rhythm propagating between both venae cavae and the tricuspid annulus (TA).1 2 3 4 5 6 7 8 9 10 For such a circuit to exist, a posterior electrical barrier is needed to prevent a short-circuiting between the posterior wall (PW) and lateral wall (LW).11 12 In humans, this barrier is related to the crista terminalis (CT).13 The fibers of this structure run longitudinally between the LW and PW in a high-to-low pattern. This structure, which is the fastest pathway in the lateral free wall in the craniocaudal direction,14 15 creates a line of block in the transversal direction that determines the activation pattern of the LW during AFL. Although the CT is an electrical barrier during AFL,11 12 13 there are no data about the conduction properties of this structure after sinus rhythm has been restored, namely, if the conduction block is functional or fixed. The recording of double electrograms is a marker of areas of conduction block, but they are observed only during reentry or when the activation wave front is perpendicular to the line of block.11 12 13 16 17 Thus, to determine whether the CT is a fixed or functional line of block, pacing was performed on both sides of the CT at several rates.
The AFL circuit is critically dependent on conduction through the cavotricuspid isthmus (CTI), and this region is the target of transcatheter ablation procedures.18 19 Because detection of CTI conduction block is based on changes in the activation patterns of the LW and interatrial septum during low LW and coronary sinus ostium (CSO) pacing,20 21 an additional purpose of the present study was to determine the influence of CT conduction properties on activation patterns of the right atrium during pacing and therefore on CTI conduction-block evaluation.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Population
The study group consisted of 22 patients with typical AFL, defined by an inverted sawtooth pattern in the inferior ECG leads and a regular atrial rate >240 bpm in the absence of antiarrhythmic drugs, referred for radiofrequency ablation of the CTI (Table 1
). At the time of the
study, patients 4 and 12 were taking amiodarone, and patient 21
was taking flecainide; the remaining patients were not taking any class
I or III antiarrhythmic drugs.
|
Electrophysiological Testing: Electrical
Stimulation and Recordings
Studies were performed with patients in a nonsedated and
postabsorptive state; written consent was obtained from each patient.
Intracardiac recordings, which were filtered between 30 and 500
Hz with a gain amplification between 0.5 and 0.1 mV/cm, were displayed
simultaneously with 
1 ECG lead (II or aVF) on a
12-channel recorder (Midas, Hellige Biomedical) at paper speeds of
100 and 200 mm/s. Atrial stimulation was performed with a
programmable stimulator (UHS-20 BiotroniK) set to deliver rectangular
pulses of 1-ms duration at twice the diastolic
threshold.
Figure 1 shows the fluoroscopic
appearance of the catheter arrangement. A "deflectable halo"
catheter (2-mm interelectrode distance, 10-mm interbipole distance;
Webster Laboratories) was placed around the TA to obtain the right
atrium activation sequence during flutter and the catheter ablation
procedure; the distal pair was located close to the ablation line at
approximately the 6-o'clock position of the TA. A quadripolar catheter
was placed at the CSO to test conduction between the septal and lateral
walls through the CTI. A third quadripolar deflectable-tip catheter was
used for radiofrequency application. This catheter was also used for CT
identification by searching the double electrogram during flutter
between the LW and PW. In 10 patients, a 20-pole deflectable catheter
(Crista Catheter, Cordis), spacing 1–3–1 mm, was placed at or in
the proximity of the CT, and the distal electrode was next to the
inferior vena cava.
|
Radiofrequency Ablation
After mapping and entrainment techniques characterized the
arrhythmia as AFL, if sinus rhythm could be restored, pacing at
both sides of the CTI was performed. Incremental pacing trains (from
600 ms to 2-to-1 atrial capture) were delivered at the CSO and from the
distal pair of the halo catheters to establish right atrium activation
patterns before radiofrequency ablation. A quadripolar deflectable-tip
catheter was used for radiofrequency application. Radiofrequency
ablation was performed with current generated by a conventional 500-kHz
radiofrequency energy source (EPT-1000, EP Technologies or Atakr,
Medtronic Cardiorhythm), delivered from the 8- or 4-mm tip of a
steerable mapping catheter (Blazer T, EP Technologies and Marinr,
Medtronic Cardiorhythm) to a left subscapular chest wall patch.
Ablation was anatomically guided and performed during AFL or sinus
rhythm. Linear lesions were produced in the CTI, and the ablation
catheter was progressively withdrawn under fluoroscopic guidance during
radiofrequency energy delivery from the TA to the
inferior vena cava (pulse duration between 90 and 120
seconds). Linear lesions were produced in the CTI in an attempt to
achieve bidirectional conduction block between the LW and interatrial
septum. To test the appearance of CTI block, the previously mentioned
pacing protocol at both sides of the CTI was repeated after each
ablation line was completed. CTI block was presumed to be present
when the activation pattern of the side opposite to the pacing site was
completely craniocaudal in nature.
CT Location
CT location was defined by recording double electrograms
during flutter in the union of the LW and PW. Frames of the right and
left anterior oblique fluoroscopic projections obtained during
mapping were used to determine the location of the CT after sinus
rhythm was restored.
Evaluation of Conduction Across the CT
After the radiofrequency ablation procedure was finished, in
cases in which the Crista catheter was not used to record CT
electrograms, the halo catheter was rotated counterclockwise and then
pulled back to achieve close contact of the distal electrodes with the
atrial wall at the proximity of the CT, so that 5 or 6 bipolar
electrograms were recorded along the CT from the high to the low
right atrium, which was done to maintain the distal electrode next to
the inferior vena cava. After a stable position of
the catheter was achieved, we proceeded to pace on both sides of the
CT. To obtain activation wave fronts perpendicular to the CT, we
selected sites from which the activation time differences among the
bipolar electrograms recorded from the low to the high atrium were
the shortest possible at the slowest rate. When it was difficult to
locate a stable position at the PW, pacing was performed at the CSO.
The second pacing site was at the low lateral right atrium. Multiple
10-second-duration synchronized trains of rapid atrial pacing at a
constant rate were delivered at decremental cycle lengths from 600 ms
until 2-to-1 atrial capture occurred.
Definitions
Double electrograms are defined as 2 discrete
deflections separated by an isoelectric interval.
Focal transversal conduction block in the CT was recognized
by the recording of double electrograms at 1 site during
pacing at the LW and PW.
Complete transversal conduction block along the CT was detected by the appearance of double electrograms at all recording sites and a change in the activation sequence, with the development of a craniocaudal activation sequence at the opposite side of the pacing site. Recording of double electrograms at the highest portion of the CT was not necessary for the assumption of complete block, because this area was considered the turning point of the activation wave front.
Constant clockwise block of the CTI was defined by observation of a completely descending activation of the LW during pacing from the CSO at 600 ms.
Rate-dependent clockwise block of the CTI was defined by the observation of 2 activation wave fronts, one ascending and the other descending, in the LW during pacing from the CSO at 600 ms, but only a single descending activation of the LW during pacing at shorter cycle lengths.
Constant counterclockwise block of the CTI was presumed to occur when the CSO electrogram was activated after the high interatrial septum and His bundle area during pacing at 600 ms from the low lateral right atrium.
Rate-dependent counterclockwise block of the CTI was presumed to occur when the CSO electrogram was activated simultaneous with or before the high interatrial septum and His bundle area during pacing at 600 ms, but later at a shorter cycle length.
Conduction interval was defined as the interval between the CSO and the low LW (poles 1 and 2 of the halo catheter) during pacing from both sites at the shortest cycle length before CT block and at the pacing cycle length that provoked complete CT block.
Statistical Analysis
Values are expressed as mean±SD. Statistical comparisons for 2
groups were performed with the Student's t test or the
signed rank test. A value of P<0.05 (2-tailed) was
considered significant.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Recordings obtained along the right atrium during flutter showed activation propagating in a counterclockwise direction in all patients. The flutter cycle length of this group was 234±23 ms. After radiofrequency ablation, constant bidirectional CTI block was observed in 17 patients, whereas 3 patients showed clockwise rate-dependent block and 2 showed both counterclockwise and clockwise rate-dependent block. During sinus rhythm, neither double nor fragmented electrograms were recorded in the CT area. (See Table 2
.)
|
Conduction Across the CT
Although complete transversal conduction block was observed in all
patients from 1 pacing site, it was observed at the longest possible
pacing cycle length in only a minority, suggesting the presence of
fixed conduction block (patients 2, 11, 12, and 20 during pacing from
the PW/CSO and patients 12 and 20 during pacing from the LW; Figure 2). In the remaining patients, the block
was rate dependent (Figure 3). As shown
in Table 2
, both partial and complete block were achieved at
longer pacing cycle lengths from the PW/CSO than from the LW. In 3
patients (patients 1, 6, and 13), complete block was not achieved with
the shortest pacing cycle length from the LW (Figure 4), which suggests pacing site–dependent
conduction block.
|
|
|
CT Conduction and CTI Block Assessment
Constant clockwise CTI block was observed in 4 and 13 patients
with fixed and rate-dependent CT conduction block, respectively. In 4
of the 5 cases in which CTI block was rate dependent (patients 15, 16,
18, and 19), the block appeared at the same cycle length as at the CT
(Figure 5). In the remaining case
(patient 14), CTI block appeared at a longer cycle length than for CT
block (Figure 6). Constant
counterclockwise CTI block was present in all but 2 patients, who
had CT rate-dependent block.
|
|
In 11 patients with rate-dependent CT conduction block, we could
measure the conduction interval between the CSO and the low LW before
and after the appearance of complete block at the CT (Table 3). It was during clockwise CTI block
testing that the conduction interval increment was significantly
greater (67±39 versus 4±4 ms; P<0.02) in patients with
rate-dependent block (Figure 5) than in patients with constant
CTI block (Figure 7).
|
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The presence of a line of block along the CT is presumed to be essential for AFL to occur. A match between wavelength and circuit size is achieved if this line of block prevents the short circuit between the PW and LW, circumscribing the macroreentry around the tricuspid ring. We have shown that CT transversal conduction block in patients with typical AFL is rate and pacing-site dependent, with the exception that in some patients, complete block did not appear during pacing from the LW. We have also shown that conduction properties are not uniform along the CT; in most patients, partial block occurs at very different pacing cycle lengths than complete block. Complete bidirectional block at the CT was usually observed only at short cycle lengths. This observation may be the reason for the narrow limits of the flutter cycle length. Reentry would remain stable if conduction time along the macroreentrant circuit was shorter than the cycle length at which CT block developed.
Differences Between PW and LW Rate-Dependent Transversal
Conduction Block
We observed that conduction block in the CT was achieved at slower
pacing rates from the PW than from the LW, where only partial block was
observed in some cases. Differences in cell arrangement between the
smooth and trabeculated atrial walls may produce a
different electrical input in the CT and consequently a different
rate-dependent block. This characteristic could explain the greater
incidence of counterclockwise rotation in spontaneous AFL. According to
CT conduction characteristics, AFL should be more easily induced by
atrial arrhythmias arising in the PW or the left atrium than by
those arising from the high and lateral right atrium, which would
require a shorter cycle length to cause complete conduction block.
Because the direction of rotation of atrial fibrillation (AF) may be
dependent on the site of induction (pacing from the PW induces
counterclockwise flutter, and pacing from the lateral right atrium
induces clockwise flutter22 23 ), counterclockwise flutter
should occur more frequently. In the same sense, atrial
arrhythmias with coupling intervals or cycle lengths that
provoke conduction block only from the PW to the LW will induce stable
flutter if propagation is counterclockwise. If conduction block is only
present from the PW to the LW and conduction is possible in the
opposite direction, the only way for the CT to act as a line of
bidirectional conduction block is if the postactivation refractoriness
of the CT, just before the line of block, exceeds the time required to
surround the line of block. This will depend on the conduction time of
the activation wave front around the CT. Therefore, when activation is
counterclockwise, propagation between both sides of the CT through the
high right atrium will have a short delay, and the CT will function as
a barrier in both directions. If activation of the opposite side of the
CT is delayed (ie, clockwise propagation through the previously
mentioned slow-conducting area located in the low atrium), the barrier
of refractoriness could end, because there is enough time to recover
and conduction to the other side of the CT is possible at some level of
the CT, thus creating smaller and more unstable circuits. This
hypothesis could explain why counterclockwise right atrium circus
movement is more commonly observed than clockwise movement in type 1
AFL. Nevertheless, some other determinants are presumably involved,
because AFL in transplanted hearts is usually counterclockwise despite
the lack of any role for the CT in the flutter
mechanism.24
Influence of CT Rate-Dependent Conduction Block on the Evaluation
of CTI Block
The CTI is commonly used as the target of radiofrequency
ablation.18 19 Achievement of constant block at this
isthmus is the best marker of success.20 21 Nevertheless,
rate-dependent block does not imply recurrence during
follow-up.21 25 A complete craniocaudal activation pattern
of the opposite wall to the pacing site (CSO and low LW) is
consistent with CTI block. Theoretically, to observe this
activation pattern, a posterior electrical barrier should be
present to prevent short-circuiting between the PW and LW. Because
this line of block is usually functional, a change would be expected in
the activation pattern and conduction interval when functional block
appears at the CT. This hypothesis is consistent with the
observation of rate-dependent CTI block, as was seen in the cases in
which CT and CTI blocks appeared simultaneously. In these
patients, a short-circuiting of the low LW at lower rates could mimic
conduction along the CTI, thus precluding recognition of CTI block.
Permanent CTI block was observed, as expected, in all patients in whom we could demonstrate fixed block at the CT, but it was also seen in the majority of cases of rate-dependent block. This surprising observation suggests that activation of the LW, at least close to the TA, is in some cases independent of the conduction state of the CT. In these patients, the conduction interval from the CSO to the low LW is not modified by the appearance of block at the CT, probably because the conduction velocity is faster along the longitudinal fibers surrounding the TA than across the CT. In these cases, the block along the CT may be essential for the initiation of AFL but not for its perpetuation.
Study Limitations
There are several limitations to this study. The CT was identified
by the recording of double electrograms during flutter; we did
not use intravascular echocardiography.
Nevertheless, in all cases, we were able to record double
electrograms at a particular location between the LW and PW that were
stable throughout the entire pacing protocol; therefore, we can assume
there is constant location for this line of block, and the
electrophysiological implications are
identical whether the line of block is at or close to the CT. Another
limitation is that we obtained data from only 1 selected pacing site on
each side of the CT, and this paced activation wave front might be
different from that observed during flutter. Therefore, rate dependency
may be different during flutter and pacing.
Clinical Implications
The production of bidirectional block between the lateral
and septal walls in the CTI is currently being used as the end point of
radiofrequency catheter ablation of AFL.20 21
Nevertheless, in patients in whom the CT does not act as a barrier
between the LW and PW at the flutter cycle length, a clockwise rotating
circuit may not be stable because of its absence. Thus, in these
patients, it is conceivable that bidirectional block is unnecessary and
that unidirectional block between the lateral and septal walls may
suffice to treat AF by catheter ablation. In cases with rate-dependent
CTI block, it is important to determine the relationship with the CT
rate-dependent block to avoid the possibility that conduction across
the CT could mimic permeability across the CTI.
Received October 23, 1998; revision received March 11, 1999; accepted March 23, 1999.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
-
Lewis T, Feil HS, Stroud WD. Observations upon
flutter and fibrillation, II: the nature of auricular flutter.
Heart. 1920;7:191–246.
-
Rosenblueth A, Garcia-Ramos J. Studies on flutter and
fibrillation, II: the influence of artificial obstacles on experimental
auricular flutter. Am Heart J. 1947;33:677–684.
-
Kimura E, Kato S, Murao S, Ajisaka H, Koyama S, Omiya
Z. Experimental studies on the mechanism of the auricular flutter.
Tohoku J Exp Med. 1954;60:197–207.[Medline]
[Order article via Infotrieve]
-
Hayden WG, Hurley EJ, Rytand DAS. The mechanism of
canine atrial flutter. Circ Res. 1967;20:496–505.
[Abstract/Free Full Text]
-
Inoue H, Matsuo H, Takayanagi K, Murao S. Clinical and
experimental studies of the effects of atrial extrastimulation and
rapid pacing on atrial flutter cycle: evidence of macro-reentry with an
excitable gap. Am J Cardiol. 1981;48:623–631.[Medline]
[Order article via Infotrieve]
-
Cosio FG, Arribas F, Palacios J, Tascon J, Lopez-Gil
M. Fragmented electrograms and continuous electrical activity in atrial
flutter. Am J Cardiol. 1986;57:1309–1314.[Medline]
[Order article via Infotrieve]
-
Olshanky B, Okumura K, Hess PG, Waldo AL.
Demonstration of an area of slow conduction in human atrial flutter.
J Am Coll Cardiol. 1990;16:1639–1648.[Abstract]
-
Arenal A, Almendral J, San Roman D, Delcan JL,
Josephson ME. Frequency and implications of resetting and entrainment
with right atrial stimulation in atrial flutter. Am J
Cardiol. 1992;70:1292–1298.[Medline]
[Order article via Infotrieve]
-
Kalman JM, Olgin JE, Saxon LA, Fisher WG, Lee RJ, Lesh
MD. Activation and entrainment mapping defines the tricuspid annulus as
the anterior barrier in typical atrial flutter. Circulation. 1996;94:398–406.
[Abstract/Free Full Text]
-
Almendral JM, Arenal A. Electrophysiology of human
atrial flutter. In: Josephson ME, Wellens HJJ, eds.
Tachycardias: Mechanism and Management. Mount
Kisco, NY: Futura Publishing; 1993:107–119.
-
Cosio FG, Arribas F, Barbero JM. Validation of double
spike electrograms as markers of conduction delay or block in atrial
flutter. Am J Cardiol. 1988;61:775–780.[Medline]
[Order article via Infotrieve]
-
Olshansky B, Okumura K, Henthorn RW, Waldo AL.
Characterization of double potential in human atrial flutter: studies
during transient entrainment. J Am Coll Cardiol. 1990;15:833–841.[Abstract]
-
Olgin JE, Kalman JM, Fitzpatrick AP, Lesh MD. 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. 1995;92:1839–1848.
[Abstract/Free Full Text]
-
Pressler ML, Münster PN, Huang X. Gap junction
distribution in the heart: functional relevance. In: Zipes DP, Jalife
J, eds. Cardiac Electrophysiology: From Cell to Bedside.
Philadelphia, Pa: WB Saunders; 1995:144–151.
-
Yamasita T, Inoue H, Nozaki A, Sugimoto T. Role of
anatomic architecture in sustained atrial reentry and double
potentials. Am Heart J. 1992;124:938–946.[Medline]
[Order article via Infotrieve]
-
Feld G, Shahandeh-Rad F. Mechanism of double potentials
recorded during sustained atrial flutter in the canine right atrial
crush-injury model. Circulation. 1992;86:628–641.
[Abstract/Free Full Text]
-
Nakagawa H, Lazzara R, Khastgir T, Beckman KJ,
McClelland JH, Imai S, Pitha J, Becker AE, Arruda M, Gonzalez MD,
Widman LE, Rome M, Neuhauser J, Wang X, Calame J, Goudeau MD, Jackman
WM. 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. 1996;94:407–424.
[Abstract/Free Full Text]
-
Cosio FG, Lopez-Gil M, Giocolea A, Arribas F, Barroso
JL. Radiofrequency ablation of the inferior vena
cava-tricuspid valve isthmus in common atrial flutter. Am J
Cardiol. 1993;71:705–709.[Medline]
[Order article via Infotrieve]
-
Fischer B, Jaïs P, Shah DC, Chouairi S,
Haïssaguerre M, Garrigue S, Poquet F, Gencel L, Clémenty
J, Marcus FI. Radiofrequency catheter ablation of common atrial flutter
in 200 patients. J Cardiovasc Electrophysiol. 1996;7:1225–1233.[Medline]
[Order article via Infotrieve]
-
Poty H, Saoudi N, Aziz AA, Nari M, Letac B.
Radiofrequency catheter ablation of type I atrial flutter: prediction
of late success by electrophysiological
criteria. Circulation. 1995;92:1389–1392.
[Abstract/Free Full Text]
-
Cauchemez B, Haïssaguerre M, Fischer B,
Thomas O, Clémenty J, Coumel P.
Electrophysiological effects of catheter ablation
of inferior vena cava–tricuspid annulus isthmus in common
atrial flutter. Circulation.. 1996;93:284–294.
[Abstract/Free Full Text]
-
Olgin JE, Kalman JM, Saxon LA, Lee RJ, Lesh MD.
Mechanism of initiation of atrial flutter in humans: site of
unidirectional block and direction of rotation. J Am Coll
Cardiol. 1997;29:376–384.[Abstract]
-
Tai CT, Chen SA, Chiang CE, Lee SH, Ueng KC, Wen ZC,
Huang JL, Chen YJ, Yu WC, Feng AN, Chiou CW, Chang MS. Characterization
of low atrial isthmus as the slow conduction zone and pharmacological
target in typical atrial flutter. Circulation. 1997;96:2601–2611.
[Abstract/Free Full Text]
-
Arenal A, Almendral J, Muñoz R,
Villacastín J, Merino JL, Palomo J, Garcia-Robles JA, Peinado
R, Delcán JL. Mechanism and location of atrial flutter in
transplanted hearts: observations during transient entrainment from
distant sites. J Am Coll Cardiol. 1997;30:539–546.[Abstract]
-
Schwartzman D, Callans DJ, Gottlieb SD, Dillon SM,
Movsowitz C, Marchlinski FE. Conduction block in the
inferior vena caval-tricuspid valve isthmus: association
with outcome of radiofrequency ablation of type I atrial flutter.
J Am Coll Cardiol. 1996;28:1519–1531.[Abstract]
This article has been cited by other articles:
 |
|
 |
|
  A. L. Waldo and G. K. Feld Inter-Relationships of Atrial Fibrillation and Atrial Flutter: Mechanisms and Clinical Implications J. Am. Coll. Cardiol., February 26, 2008; 51(8): 779 - 786. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Maury, A. Duparc, A. Hebrard, M. El Bayomy, and M. Delay Prevalence of typical atrial flutter with reentry circuit posterior to the superior vena cava: Use of entrainment at the atrial roof Europace, February 1, 2008; 10(2): 190 - 196. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y.-J. Lin, C.-T. Tai, J.-L. Huang, T.-Y. Liu, P.-C. Lee, C.-T. Ting, and S.-A. Chen Characteristics of virtual unipolar electrograms for detecting isthmus block during radiofrequency ablation of typical atrial flutter J. Am. Coll. Cardiol., June 16, 2004; 43(12): 2300 - 2304. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T.-Y. Liu, C.-T. Tai, B.-H. Huang, S. Higa, Y.-J. Lin, J.-L. Huang, Y. Yuniadi, P.-C. Lee, Y.-A. Ding, and S.-A. Chen Functional characterization of the crista terminalis in patients with atrial flutter: implications for radiofrequency ablation J. Am. Coll. Cardiol., May 5, 2004; 43(9): 1639 - 1645. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T.-a. Matsuyama, S. Inoue, Y. Kobayashi, T. Sakai, T. Saito, T. Katagiri, and H. Ota Anatomical diversity and age-related histological changes in the human right atrial posterolateral wall Europace, January 1, 2004; 6(4): 307 - 315. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Scaglione, D. Caponi, P. Di Donna, R. Riccardi, M. Bocchiardo, G. Azzaro, S. Leuzzi, and F. Gaita Typical atrial flutter ablation outcome: correlation with isthmus anatomy using intracardiac echo 3D reconstruction Europace, January 1, 2004; 6(5): 407 - 417. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Sanders, J. B. Morton, N. C. Davidson, S. J. Spence, J. K. Vohra, P. B. Sparks, and J. M. Kalman Electrical Remodeling of the Atria in Congestive Heart Failure: Electrophysiological and Electroanatomic Mapping in Humans Circulation, September 23, 2003; 108(12): 1461 - 1468. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. B. Morton, P. Sanders, J. K. Vohra, P. B. Sparks, J. G. Morgan, S. J. Spence, L. E. Grigg, and J. M. Kalman Effect of Chronic Right Atrial Stretch on Atrial Electrical Remodeling in Patients With an Atrial Septal Defect Circulation, April 8, 2003; 107(13): 1775 - 1782. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Arenal, E. Glez-Torrecilla, M. Ortiz, J. Villacastin, J. Fdez-Portales, E. Sousa, S. del Castillo, L. Perez de Isla, J. Jimenez, and J. Almendral Ablation of electrograms with an isolated, delayed component as treatment of unmappable monomorphic ventricular tachycardias in patients with structural heart disease J. Am. Coll. Cardiol., January 1, 2003; 41(1): 81 - 92. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C.-T. Tai, J.-L. Huang, Y.-K. Lin, M.-H. Hsieh, P.-C. Lee, Y.-A. Ding, M.-S. Chang, and S.-A. Chen Noncontact three-dimensional mapping and ablation of upper loop re-entry originating in the right atrium J. Am. Coll. Cardiol., August 21, 2002; 40(4): 746 - 753. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L.-M. Rodriguez, C. Timmermans, A. Nabar, L. Hofstra, and H. J.J. Wellens Biatrial Activation in Isthmus-Dependent Atrial Flutter Circulation, November 20, 2001; 104(21): 2545 - 2550. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Schilling, N. S. Peters, J. Goldberger, A. H. Kadish, and D. W. Davies Characterization of the anatomy and conduction velocities of the human right atrial flutter circuit determined by noncontact mapping J. Am. Coll. Cardiol., August 1, 2001; 38(2): 385 - 393. [Abstract] [Full Text] [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]
|
|
|
|
|
|
R. Becker, A. Bauer, S. Metz, R. Kinscherf, J. C. Senges, K. D. Schreiner, F. Voss, W. Kuebler, and W. Schoels Intercaval Block in Normal Canine Hearts : Role of the Terminal Crest Circulation, May 22, 2001; 103(20): 2521 - 2526. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Matsuo, K. Uno, C. M. Khrestian, and A. L. Waldo Conduction left-to-right and right-to-left across the crista terminalis Am J Physiol Heart Circ Physiol, April 1, 2001; 280(4): H1683 - H1691. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Anselme, A. Savoure, A. Cribier, and N. Saoudi Catheter Ablation of Typical Atrial Flutter : A Randomized Comparison of 2 Methods for Determining Complete Bidirectional Isthmus Block Circulation, March 13, 2001; 103(10): 1434 - 1439. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Villacastin, J. Almendral, A. Arenal, N. P. Castellano, S. Gonzalez, M. Ortiz, J. Garcia, B. Vallbona, J. Moreno, J. F. Portales, et al. Usefulness of Unipolar Electrograms to Detect Isthmus Block After Radiofrequency Ablation of Typical Atrial Flutter Circulation, December 19, 2000; 102(25): 3080 - 3085. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. J. Sih, D. P. Zipes, E. J. Berbari, D. E. Adams, and J. E. Olgin Differences in organization between acute and chronic atrial fibrillation in dogs J. Am. Coll. Cardiol., September 1, 2000; 36(3): 924 - 931. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||