(Circulation. 2000;101:2178.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Right Atrial Angiographic Evaluation of the Posterior Isthmus
Relevance for Ablation of Typical Atrial Flutter
Presented in part at the 20th Congress of the European Society of Cardiology, Vienna, Austria, August 1998.
From the Department of Cardiology, University Hospital Gasthuisberg, University of Leuven (Belgium).
Correspondence to Hein Heidbüchel, MD, PhD, Cardiology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium. E-mail Hein.Heidbuchel{at}uz.kuleuven.ac.be
Background—Gaining anatomic information about the posterior isthmus is not generally part of flutter ablation procedures. We postulated that right atrial (RA) angiography could rationalize the ablation approach by revealing the conformation of the isthmus.
Methods and Results—In 100 consecutive patients, biplane RA
angiography was performed before ablation to guide catheter contact
with the isthmus along its length. Angiography showed a wide variation
in the width of the isthmus (17 to 54 mm; 31.3±7.9), its angle
with the inferior vena cava in the right anterior oblique
projection (68° to 114°; 90.3±9.0°), and its lateral
position relative to the inferior vena cava in the left
anterior oblique projection. A deep sub-Eustachian recess was
revealed in 47%, with a mean depth of 4.3±2.1 mm (1.5 to 9.4). A
Eustachian valve was visualized in 24%. Ablation resulted in
bidirectional conduction block (which could be transient) in all, with
a median of 2 dragging radiofrequency (RF) applications (2.3±2.5 RF
applications; 57°C, 
99 seconds each). Permanent block was achieved
in 99%, with a median of 3 RF applications (3.4±3.0). The presence of
a Eustachian valve or concave isthmus was associated with statistically
more RF applications; the same trend was seen for patients with deep
pouches. The number of RF applications decreased statistically
throughout the study, indicating a learning curve. No patient had a
recurrence after a follow-up of 13±11 months.
Conclusions—Right atrial angiography reveals a highly variable isthmus anatomy, often showing particular configurations that can make ablation more laborious. Rational adaptation of the ablation approach to these anatomic findings may contribute to successful ablation.
Key Words: atrial flutter • catheter ablation • angiography • structure
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