Coronary Sinus Activation and ECG Characteristics of Roof-Dependent Left Atrial Flutter After Pulmonary Vein Isolation

Abstract

BACKGROUND:The electrocardiographic and intracardiac activation features of left atrial roof-dependent macroreentrant flutter have been incompletely characterized. METHODS:Patients post-pulmonary vein (PV) isolation with roofdependent atrial flutter based on activation and entrainment mapping were included. ECG and coronary sinus activation were compared with mitral annular (MA) flutter. RESULTS:The roof-dependent left atrial flutter circled the right PVs in 32 of 33 cases. Two forms of roof flutters were identified, posteroanterior, ascendant on posterior wall and descendant on anterior wall (n=24); and anteroposterior, ascendant on the anterior wall and descendent on the posterior wall (n=9). Both forms had positive large amplitude P waves in V 1 through V 2 with decreasing amplitude in V 3 through V 6 . Posteroanterior roof flutters had positive P wave in the inferior and negative P wave in leads I and aVL similar to counterclockwise MA flutter, but coronary sinus activation was simultaneous for roof and proximal to distal for counterclockwise. Anteroposterior roof flutters were similar to clockwise MA flutter with negative P in inferior leads and transition to flat or negative P in V 3 through V 6 . Coronary sinus activation time ≤39 ms identified roof versus MA flutter (sensitivity: 100% and specificity: 97%). CONCLUSIONS:Roof-dependent flutter around right PVs is more common than around left PVs. The ECG pattern for roof-dependent flutter around right PVs is similar to MA flutter with frontal plane axis dictated by septal activation. Roof-dependent flutter can be distinguished from MA flutter by more simultaneous rather than sequential coronary sinus activation.

Catheter ablation of atrial arrhythmias following lung transplant: Electrophysiological findings and outcomes

“…Patients with focal AAs were treated with targeted RF energy ablation at the earliest sites defined with mapping. Linear RF lesions were used to target macro‐re‐entrant AAs, as previously described 11,12 . After ablation, provocative testing using isoproterenol, adenosine, and burst atrial pacing were used to assess for PV reconnection, non‐PV triggers and additional inducible AA, as previously described 13–15 …”

Conduction time around the mitral valve annulus has the potential to rule out postablation perimitral atrial tachycardia

“…17 Even if activation maps cannot be acquired for the whole atrium during atrial tachycardia, it has been reported that CS sequence can be used to estimate atrial tachycardia circuits such as PMAT and roof-dependent atrial tachycardia. 18,19 However, the E-PMCT reported in this study has the advantage of being able to estimate PMAT even if the tachycardia terminates before the CS catheter is inserted and cannot be induced afterwards, if a mapping of the previous session in which E-PMCT was measurable is available.…”

Atrial Tachycardias After Atrial Fibrillation Ablation: How to Manage?

“…[ 54 ] Casado Arroyo et al stated that a CS activation time ≤39 ms can assist in the diagnosis of roof-dependent ATs with a sensitivity of 100% and specificity of 97%. [ 55 ]…”