(Circulation. 1996;94:407-424.)
© 1996 American Heart Association, Inc.
Articles |
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
the Department of Medicine, University of Oklahoma Health Sciences Center, and the Department of Veterans Affairs Medical Center, Oklahoma City, Okla, and Academic Medical Center (A.E.B.), Amsterdam, Netherlands.Presented in part at the 14th Annual Scientific Sessions of the North American Society of Pacing and Electrophysiology, May 1993, San Diego, Calif.
Correspondence to Warren M. Jackman, MD, Department of Medicine/Cardiovascular Section, University of Oklahoma Health Sciences Center, 920 SL Young Blvd, Room 5SP300, Oklahoma City, OK 73104.
Background Typical atrial flutter (AFL) results from right atrial reentry by propagation through an isthmus between the inferior vena cava (IVC) and tricuspid annulus (TA). We postulated that the eustachian valve and ridge (EVR) forms a line of conduction block between the IVC and coronary sinus (CS) ostium and forms a second isthmus (septal isthmus) between the TA and CS ostium.
Methods and Results Endocardial mapping in 30 patients with AFL demonstrated atrial activation around the TA in the counterclockwise direction (left anterior oblique projection). Double atrial potentials were recorded along the EVR in all patients during AFL. Pacing either side of the EVR during sinus rhythm also produced double potentials, which indicated fixed anatomic block across EVR. Entrainment pacing at the septal isthmus and multiple sites around the TA produced a 
return interval 
8 ms in 14 of 15 patients tested. Catheter ablation eliminated AFL in all patients by ablation of the septal isthmus in 26 patients and the posterior isthmus in 4. AFL recurred in 2 of 12 patients (mean follow-up, 33.9±16.3 months) in whom ablation success was defined by the inability to reinduce AFL, compared with none of 18 patients (mean follow-up, 10.3±8.3 months) in whom success required formation of a complete line of conduction block between the TA and the EVR, identified by CS pacing that produced atrial activation around the TA only in the counterclockwise direction and by pacing the posterior TA with only clockwise atrial activation.
Conclusions (1) The EVR forms a line of fixed conduction block between the IVC and the CS; (2) the EVR and the TA provide boundaries for the AFL reentrant circuit; and (3) verification of a complete line of block between the TA and the EVR is a more reliable criterion for long-term ablation success.
Key Words: atrial flutter • mapping • catheter ablation • radiofrequency
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