title: Anatomical variations of the right coronary artery may be a source of difficult block and conduction recurrence in catheter ablation of common-type atrial flutter.
abstract: OBJECTIVE
  Although Eustachian valves and recesses have been related to resistance to block, the effect of convective cooling by the right coronary artery (RCA) has not been evaluated in the clinical setting.
  
  
  RESULTS
  The distance and course of the RCA in relation to the cavotricuspid isthmus (CTI) in addition to variants of CTI anatomy and the presence of Eustachian valves were analysed from computed tomography scans of 54 patients. Ablation power was titrated using a step-up protocol. Invasive follow-up was available for 34 patients. The RCA came closest to the CTI inferiorly separated by a mean of 5.3 ± 2.5 mm compared with 7.3 ± 3.3 mm septally and 5.7 ± 2.3 mm anteriorly (P < 0.01). The maximum power required for CTI block correlated inversely with the distance of the RCA to the CTI, whereas the cumulative energy was highest in the presence of recesses. Neither failure of acute block nor a higher rate of conduction recurrence could be attributed to variants of CTI anatomy or the presence of a Eustachian valve. Using multivariate analysis, a position of the RCA underneath the central part of the CTI was the only significant predictor for late conduction recurrence. These patients showed a 2.7 mm larger distance of the RCA to the tricuspid valve plane (P = 0.05).
  
  
  CONCLUSIONS
  The RCA affects CTI ablation as higher power settings are required at closer distances to the ablation site. Late conduction recurrences were observed in patients with a variation of the RCA, leaving the atrioventricular groove towards the atrial aspect.
authors.affiliation: Department of Cardiology, Heart Center Dortmund, Beurhausstrasse 40, 44137 Dortmund, Germany. hanno.klemm@klinikumdo.de
authors.forename: Hanno U
authors.initials: HU
authors.lastname: Klemm
authors.forename: Tim F
authors.initials: TF
authors.lastname: Weber
authors.forename: Christin
authors.initials: C
authors.lastname: Johnsen
authors.forename: Philipp G C
authors.initials: PG
authors.lastname: Begemann
authors.forename: Thomas
authors.initials: T
authors.lastname: Meinertz
authors.forename: Rodolfo
authors.initials: R
authors.lastname: Ventura
mesh_terms: D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001282:Atrial Flutter / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation; D003331:Coronary Vessels / Q000033:anatomy & histology*; D005260:Female; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014261:Tricuspid Valve / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D014682:Vena Cava, Inferior / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*
chemical_list: D000889:Anti-Arrhythmia Agents