Further Evidence for the “Muscle Bundle” Hypothesis of Cavotricuspid Isthmus Conduction: Physiological Proof, with Clinical Implications for Ablation

Mechulan, Alexis; Gula, Lorne J.; Klein, George J.; Leong‐Sit, Peter; Obeyesekere, Manoj; Krahn, Andrew D.; Yee, Raymond; Skanes, Allan C.

doi:10.1111/j.1540-8167.2012.02415.x

Cited by 13 publications

(8 citation statements)

References 28 publications

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“…This result highlights a crucial point regarding CTI anatomy. Hence, it is well recognized that the CTI is composed of electrically active muscular bundles separated by layers of non‐conducting connective tissue . Moreover, at the opposite of the classical flat and straight morphology, near to one‐half of the CTI exhibits at least one anatomic variation such as prominent Eustachian ridge, deep pouch, or marked concavity with protruding bundles …”

Section: Discussionmentioning

confidence: 99%

“…Hence, it is well recognized that the CTI is composed of electrically active muscular bundles separated by layers of non-conducting connective tissue. 3,21,22 Moreover, at the opposite of the classical flat and straight morphology, near to one-half of the CTI exhibits at least one anatomic variation such as prominent Eustachian ridge, deep pouch, or marked concavity with protruding bundles. 4 Since closely packed bundles associated with a discrete Eustachian ridge allow for good catheter contact, the straight CTI ensures simple achievement and evaluation of a complete lesion line.…”

Section: Positive Predictive Value Of First Positive Unipolar Line Comentioning

confidence: 99%

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Modification of the Unipolar Atrial Electrogram as a Local Endpoint During Common Atrial Flutter Ablation

Pambrun¹,

Roig²,

Bouzeman³

et al. 2015

Cardiovasc electrophysiol

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Section: Discussionmentioning

confidence: 99%

Section: Positive Predictive Value Of First Positive Unipolar Line Comentioning

confidence: 99%

Modification of the Unipolar Atrial Electrogram as a Local Endpoint During Common Atrial Flutter Ablation

Pambrun¹,

Roig²,

Bouzeman³

et al. 2015

Cardiovasc electrophysiol

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“…[3–12,15] First, it is a nonrandomized study performed by medical staff that are already trained in NXR. [11] The success of the ablation procedure was confirmed acutely and within the observation period.…”

Section: Limitationsmentioning

confidence: 99%

Maximum voltage gradient technique for optimization of ablation for typical atrial flutter with zero-fluoroscopy approach

Deutsch¹,

Śledź²,

Mazij³

et al. 2017

Medicine

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Radiofrequency catheter ablation (RFCA) is an established effective method for the treatment of typical cavo-tricuspid isthmus (CTI)-dependent atrial flutter (AFL). The introduction of 3-dimensional electro-anatomic systems enables RFCA without fluoroscopy (No-X-Ray [NXR]). The aim of this study was to evaluate the feasibility and effectiveness of CTI RFCA during implementation of the NXR approach and the maximum voltage-guided (MVG) technique for ablation of AFL.Data were obtained from prospective standardized multicenter ablation registry. Consecutive patients with the first RFCA for CTI-dependent AFL were recruited. Two navigation approaches (NXR and fluoroscopy based as low as reasonable achievable [ALARA]) and 2 mapping and ablation techniques (MVG and pull-back technique [PBT]) were assessed. NXR + MVG (n = 164; age: 63.7 ± 9.5; 30% women), NXR + PBT (n = 55; age: 63.9 ± 10.7; 39% women); ALARA + MVG (n = 36; age: 64.2 ± 9.6; 39% women); and ALARA + PBT (n = 205; age: 64.7 ± 9.1; 30% women) were compared, respectively. All groups were simplified with a 2-catheter femoral approach using 8-mm gold tip catheters (Osypka AG, Germany or Biotronik, Germany) with 15 min of observation. The MVG technique was performed using step-by-step application by mapping the largest atrial signals within the CTI.Bidirectional block in CTI was achieved in 99% of all patients (P = NS, between groups). In NXR + MVG and NXR + PBT groups, the procedure time decreased (45.4 ± 17.6 and 47.2 ± 15.7 min vs. 52.6 ± 23.7 and 59.8 ± 24.0 min, P < .01) as compared to ALARA + MVG and ALARA + PBT subgroups. In NXR + MVG and NXR + PBT groups, 91% and 98% of the procedures were performed with complete elimination of fluoroscopy. The NXR approach was associated with a significant reduction in fluoroscopy exposure (from 0.2 ± 1.1 [NXR + PBT] and 0.3 ± 1.6 [NXR + MVG] to 7.7 ± 6.0 min [ALARA + MVG] and 9.1 ± 7.2 min [ALARA + PBT], P < .001). The total application time significantly decreased in the MVG technique subgroup both in NXR and ALARA (P < .01). No major complications were observed in either groups.Complete elimination of fluoroscopy is feasible, safe, and effective during RFCA of CTI in almost all AFL patients without cardiac implanted electronic devices. The most optimal method for RFCA of CTI-dependent AFL seems to be MVG; however, it required validation of optimal RFCA's parameters with clinical follow-up.

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“…While the cavotricuspid isthmus is the anatomical basis for typical atrial flutter, it is the anisotropic properties of musculature in this region that may facilitate reentry . Similarly, while a ventricular infarct is “structural,” it promotes reentry “functionally” by gap junctional remodeling, conduction slowing and repolarization dispersion in the penumbra or in trans‐infarct channels …”

Section: Editorial Commentmentioning

confidence: 99%

When Is Structure, Function? Revisiting an Old Concept in Atrial Fibrillation

Zaman

Narayan

2015

Cardiovasc electrophysiol

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Further Evidence for the “Muscle Bundle” Hypothesis of Cavotricuspid Isthmus Conduction: Physiological Proof, with Clinical Implications for Ablation

Cited by 13 publications

References 28 publications

Modification of the Unipolar Atrial Electrogram as a Local Endpoint During Common Atrial Flutter Ablation

Modification of the Unipolar Atrial Electrogram as a Local Endpoint During Common Atrial Flutter Ablation

Maximum voltage gradient technique for optimization of ablation for typical atrial flutter with zero-fluoroscopy approach

When Is Structure, Function? Revisiting an Old Concept in Atrial Fibrillation

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