Simple and efficient identification of conduction gaps in post-ablation recurring atrial flutters.
OBJECTIVE
Cavo-tricuspid isthmus (CTI) radiofrequency (RF) ablation is a curative therapy for common atrial flutter (AFl), but is associated with a recurrence rate of 5-26%. Although complete bidirectional conduction block is usually achieved, the recurrence of AF is due to recovered conducting isthmus tissue through which activation wavefronts pass. We evaluated a simple and efficient electrophysiological strategy, which pinpoints the ablation target.


RESULTS
Twenty-five patients (19 men), mean age 61 +/- 6, with recurrent AFl required a repeat ablation, 250 +/- 160 days after a successful RF CTI procedure. Transverse CTI conduction was monitored during AFl or coronary sinus (CS) pacing by a 24-pole mapping catheter positioned in the right atrium (RA), with the distal poles in the CS, proximal poles on the lateral RA, and intermediate poles on the CTI. A slow conduction area traversing the CTI (velocity, 37 +/- 22 vs. 98 +/- 26 cm/s on either side, P < 0.05) and a lower potential amplitude than at both sides (0.2 +/- 0.15 vs. 0.5 +/- 0.5 mV, P < 0.05), defined by a bayonet-shaped depolarization sequence, were considered to represent the incomplete line of block (InLOB). An ablation catheter was progressively dragged up to this InLOB, from the tricuspid annulus to the inferior vena cava, analysing the widely separated double potentials (DPs) until these coalesced. In nine patients (35%), the target conduction gap was a coalesced fractionated atrial potential within the InLOB (duration, 77 +/- 12 ms), and in 16 patients (65%), a narrow DP toward the healthy margins of this InLOB (duration, 28 +/- 15 ms). Adopting this strategy yields 100% successful re-ablation of recurring AFl leading to bidirectional block, with a mean 2.7 +/- 1.4 RF applications.


CONCLUSIONS
Transverse CTI mapping precisely locates the InLOB and helps find conduction gaps along the CTI in re-ablation procedures for common AFl.
Laurent
Gabriel
G
Department of Cardiology, University Hospital Dijon, Hôpital Bocage, 3 Bd de Lattre de Tassigny, 21000 Dijon, France. gaby.nathalie@free.fr
De Chillou
Christian
C
Bertaux
Géraldine
G
Poull
Isabelle Magnin
IM
Martel
Alexandra
A
Andronache
Marius
M
Fromentin
Stéphane
S
Fraison
Michel
M
Gonzalez
Stéphanie
S
Pierre
François Saint
FS
Aliot
Etienne
E
Wolf
Jean Eric
JE
D001282:Atrial Flutter / Q000503:physiopathology* / Q000601:surgery*; D017115:Catheter Ablation; D004562:Electrocardiography; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006329:Heart Conduction System / Q000503:physiopathology* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012086:Reoperation; D016896:Treatment Outcome; D014261:Tricuspid Valve / Q000503:physiopathology / Q000601:surgery; D014682:Vena Cava, Inferior / Q000503:physiopathology / Q000601:surgery