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Atypical left atrial flutter may occur as a complication after atrial fibrillation ablation, especially when linear and substrate ablation were initially deployed. In such cases, the most effective therapy is radiofrequency ablation, but the procedure can be long lasting and challenging. Use of multielectrode catheters and high-density mapping algorithms together with a conventional electrophysiological approach may shorten and simplify treatment. Case reportA 43-year-old woman, after previous ablations for atrial fibrillation and typical atrial flutter, was scheduled for another ablation, due to symptomatic atypical atrial flutter. Echocardiography showed left atrial (LA) diameter within the normal range (40 mm) and normal ejection fraction (65%).Previously the patient underwent circumferential pulmonary vein isolation and linear ablation with lines in the cavo-tricuspid isthmus (CTI), left atrial roof and mitral isthmus groove. During the last ablation, bi-directional block was confirmed in all locations and no arrhythmia was induced with aggressive stimulation during isoproterenol infusion.The ECG recorded on admission suggested left atrial flutter with 2:1 conduction, with positive F waves in leads II, III, aVF, and V1 and negative in leads aVR and AVL (Fig. 1). Intracardiac signals (IC) showed atrial flutter with CL 295-300 ms, with proximal and distal bipoles at the catheter placed in the coronary sinus (CS) activated simultaneously.Due to the electrographic pattern of arrhythmia and previous catheter ablations the operator (JK) decided to perform high-density mapping of left atrial endocardial activation using a multielectrode mapping (MEM) catheter (PentaRay, 20 poles, spacing 2-6-2, 1 mm width electrodes) and dedicated automatic algorithm[1] (Confidense, Carto 3 Biosense Webster).

We present a case of a 16‐year‐old male with WPW syndrome, referred for ablation after being resuscitated from cardiac arrest. Bipolar transseptal RF ablation successfully destroyed rapidly conducting epicardial posteroseptal accessory pathway after three failed attempts of endo‐ and epicardial ablation.

The aim of the study was to provide quantitative data and to look for new landmarks useful during transseptal puncture (TSP) using a fluoroscopy‐guided approach. Methods and results A total of 104 patients at mean age 57 ± 12 years, of whom 92% underwent pulmonary vein isolation, were analysed. Before TSP catheters were placed in the coronary sinus (CS) and His bundle region. A guidewire running from femoral vein through great veins was left loose in superior vena cava. Before TSP X‐ray images were taken in right anterior oblique (RAO) 45° and RAO 53° projections. Locations posterior to TSP site in RAO were described with negative values and those anterior with positive values. The measured distances in millimeters were as follows: (a) between TSP site and posterior atrial wall (RAO 45 = –21 ± 7 mm; RAO 53 = –19 ± 6 mm (b) between TSP site and free guidewire (RAO 45 = –5 ± 4 mm, RAO 53 = –3 ± 4 mm (c) between TSP site and CS ostium (RAO 45 = 9 ± 6 mm; RAO 53 = 8 ± 5 mm (d) between TSP site and His region (RAO 45 = 29 ± 8 mm; RAO 53 = 30 ± 8 mm). We observed correlations between measured distances and age, body mass index and sizes of cardiac chambers. The distance between TSP site and the line projected by the guidewire running between great veins, measured in mid‐RAO projections, was very small. Conclusion The distances between TSP site and standard anatomical landmarks used during TSP vary with regard to age, physique and cardiac chamber dimensions. TSP site, as assessed in mid RAO, is in direct vicinity to the line projected by a guidewire running between the great veins.

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