title: Misleading long post-pacing interval after entrainment of typical atrial flutter from the cavotricuspid isthmus.
abstract: OBJECTIVE
  The purpose of this study was to evaluate the prevalence and mechanism of a misleading long post-pacing interval (PPI) upon entrainment of typical atrial flutter (AFL) from the cavotricuspid isthmus (CTI).
  
  
  BACKGROUND
  In typical AFL, the PPI from entrainment at the CTI is expected to closely match the tachycardia cycle-length (TCL).
  
  
  METHODS
  Sixty patients with confirmed CTI-dependent AFL were retrospectively analyzed and grouped into short (≤30 ms) or long (>30 ms) PPI-TCL. Thereafter, we prospectively studied 16 patients to acquire the PPI-TCL at 4 CTI sites with entrainment at pacing cycle-lengths (PCLs) 10 to 40 ms shorter than the TCL. Conduction times during AFL and entrainment were compared in 5 segments of the AFL circuit.
  
  
  RESULTS
  Eleven patients (18%) in the retrospective analysis had a long PPI-TCL after entrainment from the CTI. Subjects with long PPI-TCL had similar baseline characteristics but greater beat-to-beat TCL variability. In the prospective cohort, PPI-TCL was influenced by the difference between PCL and TCL and site of entrainment. Conduction delays associated with a long PPI-TCL were located predominantly in the segment activated first by the paced orthodromic wave front, and were mainly due to local pacing latency, as confirmed by the use of monophasic action potential catheters.
  
  
  CONCLUSIONS
  A long PPI upon entrainment of typical AFL from the CTI is common and due to delayed conduction with entrainment. Whether these findings apply to other macro-re-entrant tachycardias warrants further investigation.
authors.affiliation: Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Strasse 40, Göttingen, Germany. d.vollmann@med.uni-goettingen.de
authors.forename: Dirk
authors.initials: D
authors.lastname: Vollmann
authors.forename: William G
authors.initials: WG
authors.lastname: Stevenson
authors.forename: Lars
authors.initials: L
authors.lastname: Lüthje
authors.forename: Christian
authors.initials: C
authors.lastname: Sohns
authors.forename: Roy M
authors.initials: RM
authors.lastname: John
authors.forename: Markus
authors.initials: M
authors.lastname: Zabel
authors.forename: Gregory F
authors.initials: GF
authors.lastname: Michaud
mesh_terms: D000368:Aged; D001282:Atrial Flutter / Q000503:physiopathology* / Q000628:therapy; D018780:Body Surface Potential Mapping; D002304:Cardiac Pacing, Artificial; D017115:Catheter Ablation; D005260:Female; D005500:Follow-Up Studies; D006329:Heart Conduction System / Q000503:physiopathology* / Q000601:surgery; D006339:Heart Rate; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D014261:Tricuspid Valve / Q000503:physiopathology*