title: Mechanisms of organized left atrial tachycardias occurring after pulmonary vein isolation.
abstract: BACKGROUND
  A proarrhythmic consequence of pulmonary vein (PV) isolation can be a recurrent organized left atrial (LA) tachycardia after ablation. This arrhythmia is frequently referred to as "left atrial flutter," but the mechanism and best ablation strategy have not been determined.
  
  
  RESULTS
  Isolation of arrhythmogenic PVs was initially performed by segmental ostial PV ablation guided by a circular mapping catheter in 341 patients. Patients whose predominant recurrent arrhythmia was a persistent organized tachycardia returned for mapping and ablation. Recurrent organized LA tachycardias (cycle length 253+/-33 ms, range 213 to 328 ms) occurred in 10 (2.9%) of 341 patients (age 59+/-9 years, 1 woman). Mapping was consistent with a focal origin in 8 patients and with macroreentry in 1 patient and was unclear in 1 patient owing to degeneration to atrial fibrillation. Focal tachycardias originated from reconnected segments of prior isolated PVs (6 patients), the posterior LA (1 patient), or the superior septum (1 patient). Focal atrial tachycardias were ablated with point lesions that targeted the earliest activation. All reconnected PVs were also reisolated. Reentrant LA flutter occurred around the left PVs in 1 patient. After 6.7+/-2.3 months of follow-up, 9 (90%) of 10 patients were arrhythmia free (4 of whom were taking antiarrhythmic drug therapy), and one was having recurrent atrial fibrillation.
  
  
  CONCLUSIONS
  Recurrent organized LA tachycardia after PV isolation is uncommon and typically has a focal origin from reconnected PV ostia. Reisolation of the PV and ablation of non-PV foci are sufficient to treat this proarrhythmia. Linear lesions are only required when a macroreentrant mechanism is present.
authors.affiliation: Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce St, Philadelphia, PA 19104, USA. edward.gerstenfeld@uphs.upenn.edu
authors.forename: Edward P
authors.initials: EP
authors.lastname: Gerstenfeld
authors.forename: David J
authors.initials: DJ
authors.lastname: Callans
authors.forename: Sanjay
authors.initials: S
authors.lastname: Dixit
authors.forename: Andrea M
authors.initials: AM
authors.lastname: Russo
authors.forename: Hemal
authors.initials: H
authors.lastname: Nayak
authors.forename: David
authors.initials: D
authors.lastname: Lin
authors.forename: Ward
authors.initials: W
authors.lastname: Pulliam
authors.forename: Sultan
authors.initials: S
authors.lastname: Siddique
authors.forename: Francis E
authors.initials: FE
authors.lastname: Marchlinski
mesh_terms: D000328:Adult; D000368:Aged; D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery*; D018880:Atrial Premature Complexes / Q000503:physiopathology / Q000601:surgery; D017115:Catheter Ablation; D004562:Electrocardiography; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000503:physiopathology; D006329:Heart Conduction System / Q000503:physiopathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000503:physiopathology*; D011667:Pulmonary Veins / Q000502:physiology / Q000601:surgery*; D012008:Recurrence; D012038:Regeneration; D013617:Tachycardia, Supraventricular / Q000503:physiopathology* / Q000601:surgery