Flutter localized to the anterior left atrium after catheter ablation of atrial fibrillation.
BACKGROUND
Organized atrial arrhythmias following atrial fibrillation (AF) ablation are typically due to recovered pulmonary vein (PV) conduction or reentry at incomplete ablation lines. We describe the role of nonablated anterior left atrium (LA) in arrhythmias observed after AF ablation.


METHODS
A total of 275 consecutive patients with paroxysmal (n = 200) or chronic (n = 75) AF had PV isolation with/without additional linear ablation at the mitral isthmus (n = 106), LA roof (n = 23), or both (n = 88). Organized arrhythmias occurring after ablation were evaluated utilizing activation and entrainment mapping.


RESULTS
Fourteen patients (11 female, 65 +/- 13 years, 10 chronic AF, 10 structural heart disease) demonstrated tachycardia localized to the anterior LA, an area not targeted by prior ablation. Eight had ECG features during sinus rhythm suggestive of impaired anterior LA conduction at baseline. These arrhythmias demonstrated a distinctive ECG flutter morphology in 7 of 10 (70%) with discrete -/+ or +/-/+ aspect in inferior leads. Mapping the anterior LA revealed electrograms spanning the entire tachycardia cycle length (325 +/- 125 msec). Entrainment was possible in all with a postpacing interval exceeding the tachycardia cycle length by 9 +/- 10 msec. Electroanatomic mapping in 6 demonstrated small reentrant circuits rotating clockwise in 4 and counterclockwise in 2. Low-amplitude, fractionated mid-diastolic potentials with long duration (200 +/- 80 msec) occupying 63 +/- 22% of the cycle length were targeted for ablation resulting in termination and subsequent noninducibility.


CONCLUSIONS
Organized arrhythmias occurring after AF ablation can be due to reentrant circuits localized to the anterior LA, predominantly in females with chronic AF, structural heart disease, and abnormal atrial conduction. They are characterized by a distinctive surface ECG and highly responsive to RF ablation at the slow conduction area.
Jaïs
Pierre
P
Hôpital Haut-Lévèque, Université Victor Ségalen, Bordeaux II, Bordeaux-Pessac, France. pierre.jais@shu-bordeaux.fr
Sanders
Prashanthan
P
Hsu
Li-Fern
LF
Hocini
Mélèze
M
Sacher
Frederic
F
Takahashi
Yoshihide
Y
Rotter
Martin
M
Rostock
Thomas
T
Bordachar
Pierre
P
Reuter
Sylvain
S
Laborderie
Julien
J
Clémenty
Jacques
J
Haïssaguerre
Michel
M
D000368:Aged; D001281:Atrial Fibrillation / Q000601:surgery*; D001282:Atrial Flutter / Q000209:etiology*; D017115:Catheter Ablation; D004562:Electrocardiography; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology*; D011667:Pulmonary Veins; D012008:Recurrence; D012086:Reoperation; D012307:Risk Factors; D018709:Statistics, Nonparametric; D016896:Treatment Outcome