Electrophysiological Characteristics of Focal Atrial Tachycardia Surrounding the Aortic Coronary Cusps

Abstract

Background-Catheter ablation of atrial tachycardia (AT) arising near the coronary cusps has been reported in limited numbers of patients. We investigated the electrophysiological characteristics of these ATs in 22 consecutive patients. Methods and Results-This study included 22 patients (mean ageϮSD, 53Ϯ11 years; 86% female) with ATs arising near the aortic coronary cusps who underwent successful ablation. Activation mapping was performed during tachycardia to identify the earliest activation site. All patients achieved successful ablation through either a retrograde aortic (nϭ19) or a transseptal (nϭ3) approach. The successful ablation sites were located in the noncoronary cusp (NCC) (nϭ16), including 3 near the junction between the NCC and right coronary cusp. The remaining 6 cases were ablated from the left coronary cusp (LCC) (nϭ3) or the left atrium posterior to the LCC (nϭ3). For most tachycardias, there were distinctive P-wave morphological features recorded for each cusp location. Furthermore, analysis of the electrogram morphological features recorded during tachycardia at successful ablation sites revealed an atrial/ventricular (A/V) ratio Ͼ1 in 14 of 16 NCC ATs; the remaining 2, from the NCC near the junction with the right coronary cusp, showed an A/V ratio Յ1. At ablation sites in the LCC, the A/V ratio was Ͻ1 (4 of 6 patients) or 1 (remaining 2 patients). During a follow-up duration of 30Ϯ13 months, all patients were free of arrhythmias without antiarrhythmic drugs. Conclusions-ATs surrounding the aortic coronary cusps can be safely and effectively ablated, with good long-term outcomes. In addition to the P-wave morphological features, the A/V ratio of the local electrogram recording during tachycardia facilitated the localization of successful sites. (Circ Arrhythm Electrophysiol. 2011;4:902-908.)

Focal Atrial Tachycardia Surrounding the Anterior Septum

“…1–3 After AAS-AT eliminated from the NCC was first reported in 2004, 12 successful ablation of AAS-ATs from the NCC, other aortic cusps, and the AMJ has been reported in more patients. 4–9,13–18 In this study, 19.2% of ATs originated from the region of the AAS, which is close to the prevalence reported by Das et al 7 (18.5%) in 2008 and Ju et al 10 (17.7%) in 2012. However, the main successful ablation sites of AAS-ATs were different among studies.…”

“…9 In this study, among the 14 patients who underwent initial ablation at the RAS, only 5 patients had successful ablation. The data from the above studies 4,7,9,10,12–18 suggest that ablation from the aortic coronary cusps and the AMJ in at least some patients with AAS-ATs is not merely an adjunctive or preferred approach, but an essential approach for a successful ablation. Anatomically, the NCC overlies the paraseptal regions of the atria, and the central fibrous body of the heart, which contains the bundle of His, is located in the interleaflet triangle between the NCC and the RCC.…”

“…Furthermore, mapping of the left side of the interatrial septum after a trans-septal puncture is sometimes necessary to identify the optimal ablation site. 9,11,16–18 After the successful ablation of AAS-AT from the NCC was first reported in 2004, 12 more case series of ATs successfully eliminated from the NCC without complications were reported. 4–10,12 Subsequently, ATs from the AAS ablated from the RCC, LCC, and AMJ were described.…”

“…We previously described the results of targeting anteroseptal ATs from the aortic coronary cusps in 22 patients. 9 Among the 16 patients with successful ablation from the NCC, initial radiofrequency ablation from the right atrium was unsuccessful in 5 patients. In 6 patients with successful ablation from the LCC or AMJ, initial ablation attempts from the right atrium were all unsuccessful.…”

Catheter Ablation of Tachyarrhythmias From the Aortic Sinuses of Valsalva

“…However, from the results of studies using a large number of patients, 8,10,11 ATs arising from the NSV (NSV-ATs) have a negative/positive P-wave in lead V1. A recent study 10 reported that the P-wave morphological features in leads I and aVL are likely to be the more useful ECG findings for distinguishing NSV-ATs from LSV-ATs: a positive P-wave in leads I and aVL was more likely to be a NSV-AT, with a negative/positive or isoelectric P-wave supportive of an LSV-AT, which can be reasonably explained by the more leftward position of the LSV compared with the NSV.…”