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ECG & EP CASES Successful Radiofrequency Catheter Ablation of Scar-related Atypical Right Atrial Tachycardia with Paroxysmal Atrial Fibrillation by Using a Three-Dimensional Mapping System Yae-Min Park Young-Hoon Kim Yae-Min Park, MD., Jong-Il Choi, MD, Hong-Euy Lim, MD, Sang-Weon Park, MD, Young-Hoon Kim, MD, PhD Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea Successful radiofrequency catheter ablation of scar-related atypical right atrial tachycardia with paroxysmal atrial fibrillation by using a three-dimensional mapping system ABSTRACT A 61-year-old woman was admitted to our institution with frequent episodes of palpitations and dyspnea caused by paroxysmal atrial tachycardia. She had a history of paroxysmal atrial fibrillation and atrial tachycardia and had previously undergone radiofrequency catheter ablation. An extensive area encompassing the crista terminalis and high septum in the right atrium was identified as the scar zone by voltage mapping. The activation map of the right atrium revealed slow activation at the crista terminalis surrounded by a lowvoltage scar zone that spread centrifugally throughout the right atrium. Focal ablation at the site of earliest low amplitude and discrete signals at the crista terminalis immediately terminated tachycardia, which was no longer inducible thereafter. This case illustrates that 3-dimensional mapping may be helpful for identifying the mechanism of arrhythmia and unusual isthmus, and thereby facilitates successful ablation. Key words: ■ atrial tachycardia ■ catheter ablation Introduction ■ 3-dimensional mapping mapping offer advantages over conventional mapping by reconstructing a 3-dimensional image Conventional techniques for radiofrequency of the cardiac chamber. catheter ablation provide less data regarding In this report, we describe a case of paroxysmal accurate spatial location and preclude accurate atrial tachycardia (AT) in which a 3-dimensional electroanatomical mapping of complex cardiac mapping system facilitated successful ablation. arrhythmia. Recent advances in electroanatomical Case Received: January 4, 2013 Accepted: March 30, 2013 Correspondence: Young-Hoon Kim, MD, PhD, Division of Cardiology, Korea University Medical Center, 126-1 Anam-Dong 5Ga, Seongbuk-Gu, Seoul, 136-705 Tel: 82-2-920-6394, Fax: 82-2-927-1478, E-mail: [email protected] 28 The Official Journal of Korean Heart Rhythm Society A 61-year-old woman presented with recurrent palpitations. Electrocardiography during the palpitations showed wide QRS tachycardia (Figure 1), ECG & EP CASES Figure 1. Baseline electrocardiography during palpitations showed wide QRS tachycardia. The mechanism was determined to be atrial tachycardia with 1:1 ventricular conduction during a previous electrophysiologic study. and 24-h Holter monitoring revealed frequent sinus, a decapolar catheter in the high right atrium, unsustained episodes of paroxysmal AT and atrial and a quadripolar catheter in the bundle of His. fibrillation (AF). She was previously diagnosed with First, the geometry of the left and right atrium paroxysmal AF 4 years ago, and it had been well- were obtained using the NavX system (St Jude controlled with antiarrhythmic medication. Medical Inc., St Paul, MN, USA). We eliminated 4 However, paroxysmal AT with 1:1 ventricular pulmonary vein potentials by circumferential antral conduction frequently occurred and the patient was ablation. Voltage mapping was performed in both highly symptomatic. Therefore, she underwent atria; the area characterized by voltages of <0.1 radiofrequency catheter ablation for paroxysmal AT mV was defined as a scar. An extensive area in 2 years ago. Focal ablation at the high right atrial right atrium, specifically the high and low crista septum eliminated AT during the previous ablation terminalis, and the high right atrial septum were session and she had been stable for 2 years prior to identified as scar zones (Figure 2). We then this event. Echocardiography revealed a mildly attempted to induce tachycardia by rapid atrial reduced left ventricular ejection fraction (40.5%) pacing. Sustained AT was induced with a cycle and slightly enlarged cardiac chambers. The length of 367 ms. The earliest activation was anteroposterior diameter of left atrium was 48.5 observed at the mid-crista terminalis area (CS 19, mm. Antiarrhythmic drugs were ineffective and 20), and the relative conduction of the right atrium sinus node dysfunction developed. She therefore to the left atrium was 2:1 (Figure 3A). The decided to undergo catheter ablation for tachycardia cycle length shortened (328 ms) and paroxysmal AT and AF. the relative conduction of the right atrium to the An electrophysiologic investigation was performed left atrium became 1:1 (Figure 3B). In an electro- by placing a duodecapolar catheter in the coronary physiologic investigation, entrainment mapping VOL.14 NO.1 29 ECG & EP CASES Figure 2. An extensive area in the right atrium encompassing the high and low crista terminalis and high right atrial septum is identified as the scar zone. excluded the cavotricuspid isthmus and left atrium without procedure-related complications and she as part of the tachycardia circuit. Additionally, an has remained free of symptomatic recurrence of activation map in the right atrium was created. It arrhythmia for 2 months. revealed slow conduction at the crista terminalis surrounded by a low-voltage scar zone that spread Discussion centrifugally throughout the right atrium. The area 30 was consistent with the site of earliest activation The present case shows that a single area of slow visualized in electrograms at 24 ms prior to P-wave conduction at the crista terminalis may act as the onset (Figure 3B). Low-amplitude, discrete critical tachycardia isthmus for atypical AT. This potentials were recorded at that site. Entrainment case further emphasizes the advantages of a 3- pacing showed perfectly concealed entrainment dimensional voltage and activation map to identify (post-pacing interval minus tachycardia cycle the mechanism of the tachycardia and slow- length of <10 ms). Therefore, this area was revealed conducting isthmuses at uncommon sites. The as the critical tachycardia focus. Focal ablation at slow-conduction area on the activation map was the site of earliest signal with an open irrigated tip proved to be the critical isthmus by arrhythmia catheter immediately terminated the tachycardia, termination during ablation. which was thereafter non-inducible. Fluoroscopic Radiofrequency catheter ablation is the treatment and 3-dimensional images of the ablation sites are of choice for several cardiac arrhythmias. The shown in Figures 4 and 5, respectively. The conventional approach using intracardiac electro- induction test was repeated and no AT or AF was grams during sinus rhythm or tachycardia has inducible. The patient was successfully discharged inherent limitations. Localization and demonstration The Official Journal of Korean Heart Rhythm Society ECG & EP CASES A B Figure 3. (A) Sustained atrial tachycardia was induced with a cycle length of 367 ms and the earliest activation at the mid-crista terminalis (CS 19, 20). (B) The tachycardia cycle length shortened (328 ms) and the relative conduction of the right atrium to left atrium was 1:1. The earliest activation with low amplitude and discrete potentials were recorded at the ablation catheter 24 ms prior to P-wave onset. Abl: ablation, CS: coronary sinus, HRA: high right atrium. of the focus or entire reentrant circuit with several potential sites for ablation and to go conventional mapping catheters remains difficult. precisely to the most suitable site. Recently, 3- Furthermore, conventional mapping techniques dimensional mapping became popular during (i.e., pacing maneuvers) are limited by the risk of electrophysiologic investigations and catheter tachycardia termination or conversion to a ablation. The mechanism of tachycardia can be 1 nonclinical arrhythmia. Moreover, 2-dimensional easily determined, and the wave front propagation fluoroscopic imaging limits the ability to evaluate and the scar zone that contributes to the VOL.14 NO.1 31 ECG & EP CASES A B Figure 4. Fluoroscopic images of ablation sites (white arrow indicates an A LAO 35˚, and B RAO 35˚, respectively). LAO: left anterior oblique; RAO: right anterior oblique. propagation map and then minimizing the ablation lesion may also avoid late recurrence of scarrelated atypical flutter or AT. In conclusion, 3D mapping may be particularly helpful in patients who have recurrent atrial flutter or AT following a previous ablation because it can identify the slow-conduction zone or breakthrough site and the scar zone easily-which can then be precisely targeted. References Figure 5. Three-dimensional image of ablation sites. Yellow point indicates the site of arrhythmia termination. tachycardia can be documented. Therefore, the use of a 3-dimensional mapping system may improve procedural outcomes and clinical success.2 In particular, the efficacies of 3-dimensional mapping of atypical atrial flutter or AT following cardiac surgery were reported.3,4 The accurate identification of tachycardia isthmus by creating a voltage and 32 The Official Journal of Korean Heart Rhythm Society 1. Jais P, Matsuo S, Knecht S, Weerasooriya R, Hocini M, Sacher F, Wright M, Nault I, Lellouche N, Klein G, Clementy J, Haissaguerre M. A deductive mapping strategy for atrial tachycardia following atrial fibrillation ablation: importance of localized reentry. J Cardiovasc Electrophysiol. 2009;20(5):480-491. 2. Shah D, Jais P, Takahashi A, Hocini M, Peng JT, Clementy J, Haissaguerre M. Dual-loop intra-atrial reentry in humans. Circulation. 2000;101(6):631-639. 3. Steven D, Rostock T, Lutomsky B, Willems S. Three-dimensional mapping of atypical right atrial flutter late after chest stabbing. Pacing Clin Electrophysiol. 2008;31(3):382-385. 4. Roten L, Pedersen M, Pascale P, Shah A, Eliautou S, Scherr D, Sacher F, Haissaguerre M. Noninvasive electrocardiographic mapping for prediction of tachycardia mechanism and origin of atrial tachycardia following bilateral pulmonary transplantation. J Cardiovasc Electrophysiol. 2012;23(5):553-555.