(Circulation. 1995;92:1839-1848.)
© 1995 American Heart Association, Inc.
Articles |
Role of Right Atrial Endocardial Structures as Barriers to Conduction During Human Type I Atrial Flutter
Activation and Entrainment Mapping Guided by Intracardiac Echocardiography
From the Section of Cardiac Electrophysiology, Department of Medicine and Cardiovascular Research Institute, University of California San Francisco.
Correspondence to Michael D. Lesh, MD, Section of Cardiac Electrophysiology, Department of Medicine and the Cardiovascular Research Institute, University of California, San Francisco, 500 Parnasus Ave, Room MU 428, Box 1354, San Francisco, CA 94143-1354. E-mail lesh@ep4.ucsf.edu.
Background The importance of barriers in atrial flutter has been demonstrated in animals. We used activation and entrainment mapping, guided by intracardiac echocardiography (ICE), to determine whether the crista terminalis (CT) and eustachian ridge (ER) are barriers to conduction during typical atrial flutter in humans.
Methods and Results In eight patients, ICE was used to guide the placement of 20-pole and octapolar catheters along the CT and interatrial septum and a roving catheter to nine sites: just posterior (1) and anterior (2) to the CT along the lateral right atrium, at the fossa ovalis (3), and just posterior and anterior to the ER at the low posterolateral (4 and 5), low posterior (6 and 7), and low posteromedial (8 and 9) right atrium. Entrainment was performed, and each site was considered within the flutter circuit if the postpacing interval–flutter cycle length (PPI-FCL) and the stimulus time–activation time (stim time-act time) were <10 msec. Split potentials were recorded along the CT with components activated in a low-to-high pattern and a high-to-low pattern. Conduction times, as percentage of FCL, were significantly different at sites on either side of the CT and ER: site 1 (33±13%) and site 2 (43±12%) (P=.02), site 4 (48±24%) and site 5 (75±8.9%) (P=.02), and site 6 (22±10%) and site 7 (82±5.3%) (P=.0009). During entrainment, no surface fusion was observed at sites 5, 7, or 9. The PPI-FCL and stim time-act time were not significantly different than 0 at sites 2, 7, 5, or 9, indicating that they were within the flutter circuit, whereas sites 1, 3, 4, and 6 were not.
Conclusions ICE enabled the correlation of functional electrophysiological properties with specific anatomic landmarks, identifying the CT and ER as barriers to conduction during human atrial flutter.
Key Words: conduction • echocardiography • mapping
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D. C. Shah, P. Jais, M. Haissaguerre, S. Chouairi, A. Takahashi, M. Hocini, S. Garrigue, and J. Clementy Three-dimensional Mapping of the Common Atrial Flutter Circuit in the Right Atrium Circulation, December 2, 1997; 96(11): 3904 - 3912. [Abstract] [Full Text]
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F. X. Roithinger, M. R. Karch, P. R. Steiner, A. SippensGroenewegen, and M. D. Lesh Relationship Between Atrial Fibrillation and Typical Atrial Flutter in Humans : Activation Sequence Changes During Spontaneous Conversion Circulation, November 18, 1997; 96(10): 3484 - 3491. [Abstract] [Full Text]
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W. G. Fisher, M. A. Pelini, and M. E. Bacon Adjunctive Intracardiac Echocardiography to Guide Slow Pathway Ablation in Human Atrioventricular Nodal Reentrant Tachycardia : Anatomic Insights Circulation, November 4, 1997; 96(9): 3021 - 3029. [Abstract] [Full Text]
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D. C. Shah, M. Haissaguerre, P. Jais, B. Fischer, A. Takahashi, M. Hocini, and J. Clementy Simplified Electrophysiologically Directed Catheter Ablation of Recurrent Common Atrial Flutter Circulation, October 21, 1997; 96(8): 2505 - 2508. [Abstract] [Full Text]
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C.-T. Tai, S.-A. Chen, C.-E. Chiang, S.-H. Lee, K.-C. Ueng, Z.-C. Wen, J.-L. Huang, Y.-J. Chen, W.-C. Yu, A.-N. Feng, et al. Characterization of Low Right Atrial Isthmus as the Slow Conduction Zone and Pharmacological Target in Typical Atrial Flutter Circulation, October 21, 1997; 96(8): 2601 - 2611. [Abstract] [Full Text]
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C. Pandozi, L. Bianconi, M. Villani, A. Castro, G. Altamura, S. Toscano, A. P. Jesi, G. Gentilucci, F. Ammirati, F. L. Bianco, et al. Local Capture by Atrial Pacing in Spontaneous Chronic Atrial Fibrillation Circulation, May 20, 1997; 95(10): 2416 - 2422. [Abstract] [Full Text]
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T. Yamashita, Y. Murakawa, K. Ajiki, and M. Omata Incidence of Induced Atrial Fibrillation/Flutter in Complete Atrioventricular Block: A Concept of `Atrial-Malfunctioning' Atrio-Hisian Block Circulation, February 4, 1997; 95(3): 650 - 654. [Abstract] [Full Text]
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H. Poty, N. Saoudi, M. Nair, F. Anselme, and B. Letac Radiofrequency Catheter Ablation of Atrial Flutter: Further Insights Into the Various Types of Isthmus Block: Application to Ablation During Sinus Rhythm Circulation, December 15, 1996; 94(12): 3204 - 3213. [Abstract] [Full Text]
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G. F. Van Hare and A. L. Waldo The Atrial Flutter Reentrant Circuit: Additional Pieces of the Puzzle Circulation, August 1, 1996; 94(3): 244 - 246. [Full Text]
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P. Papageorgiou, K. Monahan, N. G. Boyle, M. J. Seifert, P. Beswick, J. Zebede, L. M. Epstein, and M. E. Josephson Site-Dependent Intra-Atrial Conduction Delay: Relationship to Initiation of Atrial Fibrillation Circulation, August 1, 1996; 94(3): 384 - 389. [Abstract] [Full Text]
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J. M. Kalman, J. E. Olgin, L. A. Saxon, W. G. Fisher, R. J. Lee, and M. D. Lesh Activation and Entrainment Mapping Defines the Tricuspid Annulus as the Anterior Barrier in Typical Atrial Flutter Circulation, August 1, 1996; 94(3): 398 - 406. [Abstract] [Full Text]
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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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 S. K. Gandhi, B. I. Bromberg, and C. B. Huddleston Surgical technique and atrial arrhythmias after total cavopulmonary connection J. Thorac. Cardiovasc. Surg., June 1, 1996; 111(6): 1291 - 1292. [Full Text]
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 S. K. Gandhi, B. I. Bromberg, M. D. Rodefeld, R. B. Schuessler, J. P. Boineau, J. L. Cox, and C. B. Huddleston Lateral Tunnel Suture Line Variation Reduces Atrial Flutter After the Modified Fontan Operation Ann. Thorac. Surg., May 1, 1996; 61(5): 1299 - 1309. [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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