Incremental Pacing for the Diagnosis of Complete Cavotricuspid Isthmus Block During Radiofrequency Ablation of Atrial Flutter

Bazán, Víctor; Martí‐Almor, Julio; Pérez-Rodón, Jordi; Bruguera, Jordi; Gerstenfeld, Edward P.; Callans, David J.; Marchlinski, Francis E.

doi:10.1111/j.1540-8167.2009.01562.x

Cited by 24 publications

(16 citation statements)

References 22 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Assessment of complete CTI block after ablation was performed by standard electrophysiologic maneuvers, including incremental atrial pacing from the lateral right atrium and the coronary sinus ostium. 18 adherence of at least 4 h per night (two in the AF arm and two in the AF plus AFib arm).…”

Section: Cardiac Evaluation and Cti Ablationmentioning

confidence: 99%

Obstructive Sleep Apnea in Patients With Typical Atrial Flutter

Bazán¹,

Grau

Vallès³

et al. 2013

Chest

Self Cite

View full text Add to dashboard Cite

Section: Cardiac Evaluation and Cti Ablationmentioning

confidence: 99%

Obstructive Sleep Apnea in Patients With Typical Atrial Flutter

Bazán¹,

Grau

Vallès³

et al. 2013

Chest

Self Cite

View full text Add to dashboard Cite

“…The lack of additional DP delays during incremental pacing may not necessarily indicate complete transisthmus block, but to select a subset of patients in whom no additional ablation is needed results from the relatively lower recurrence of atrial flutter compared with DP delay subgoup. A cut‐off value of longer than a 20 ms increase in the DP intervals mapped along the isthmus ablative line during incremental pacing is indicative of incomplete isthmus block with a higher recurrence rate of atrial flutter derived by the author 22 . The diagnostic utility of this maneuver should be established in a large scale, randomized trial with a longer clinical follow‐up.…”

Section: Editorial Commentmentioning

confidence: 94%

“…In this issue of Journal of Cardiovascular Electrophysiology , the incremental pacing maneuver proposed by Bazan et al . has provided a promising tool to determine the subgroup of patients in which a rate‐dependent increase in the intervals of the double potentials (DPs) after ablation had a higher recurrence rate of atrial flutter 22 . The presence of widely split double potentials along the line of ablation not being assessable due to ambiguous or atypical double potentials was reported by Anselme et al .…”

Section: Editorial Commentmentioning

confidence: 99%

Slow Conduction or Block of the Cavotricuspid Isthmus—Treat or Trick?

Chang

Chen

2009

Cardiovasc electrophysiol

View full text Add to dashboard Cite

Editorial CommentIn the earlier experience of atrial flutter ablation, up to 50% of patients had a recovery of cavotricuspid isthmus conduction during 1-12 months of follow-up with a cumulative recurrence of atrial flutter after the radiofrequency ablation for right atrial typical flutter of 5-10%. 1,2 An incomplete conduction block with a residual slow-conduction gap, as small as 8 mm, in the ablation line accounts for most acute or late recurrences of atrial flutter. 3 The radiofrequency application may slow the conduction velocity to 0.3 m/sec, which can mimic a complete isthmus block even when meticulous pacing and mapping are performed. 4 The identification of complete bidirectional isthmus conduction block still remains as the best predictor of the long-term success for the ablation of typical atrial flutter. 5,6 Vigorous attempts had been made to differentiate complete isthmus block from the slow conduction of the isthmus (Table 1). A change in the activation sequence recorded from a duodecapolar catheter positioned parallel to the tricuspid annulus, if the ablation is performed during septal pacing, indicates bidirectional block of the isthmus conduction. RV pacing was also used successfully to monitor continuously the atrial activation sequence during the ablation in cases in which it was difficult to achieve constant septal pacing. 7 The transisthmus activation time measured as the separation between the components of the double potentials has been used to identify complete block. A positive predictive value of 100% has been proposed for a separation of 110 ms and a specificity of 80% for a 50% increase in the transisthmus conduction time from baseline. 8-10 A change in the terminal P-wave from negative to positive in leads II, III, and aVF when pacing from the low RA could reflect cavotricuspid isthmus block due to the loss of the ascending activation along the RA wall opposite the pacing site, but it did not help differentiate between complete block and very slow conduction. 11,12 Further, a change in the unipolar electrogram from an RS configuration to a single positive R-wave and a polarity change in the initial deflection of the

show abstract

“…In the present case, the linear ablation lesion with a gap resulted in extremely slow conduction across the isthmus. This allowed a detour of the wavefront around the isthmus during pacing in its vicinity, reaching the opposite side of the ablated line earlier, and creating apparent complete block through cavotricuspid isthmus 9 . The presence of slow conduction across the isthmus, which was unmasked neither by activation mapping along the TA nor by differential pacing, became apparent only after the development of isthmus‐dependent AFL.…”

Section: Commentarymentioning

confidence: 99%

“…This allowed a detour of the wavefront around the isthmus during pacing in its vicinity, reaching the opposite side of the ablated line earlier, and creating apparent complete block through cavotricuspid isthmus. 9 The presence of slow conduction across the isthmus, which was unmasked neither by activation mapping along the TA nor by differential pacing, became apparent only after the development of isthmus-dependent AFL. The conduction gap, consistent with the ablated line, may be indicative of persistence of slow conduction during ongoing AFL after apparent complete cavotricuspid isthmus ablation.…”

Section: Commentarymentioning

confidence: 99%

Atrial Flutter After Cavotricuspid Isthmus Ablation: What is the Mechanism?

Kaneko

Nakajima

Irie

et al. 2011

Journal of Cardiovascular Electrophysiology

View full text Add to dashboard Cite

A 56-year-old man free from structural heart disease underwent radiofrequency (RF) catheter ablation of drugrefractory paroxysmal atrial flutter (AFL). A decapolar catheter was advanced with its proximal 9 and 10 poles placed in the proximal coronary sinus (CS), and a Halo deflectable duodecapolar catheter was positioned parallel to the tricuspid annulus (TA), across the inferior vena cava (IVC)-TA isthmus, with its tip at the CS ostium. During electrophysiologFigure 1. A: Surface electrocardiographic recording of the initiation of typical atrial flutter-like rhythm following atrial fibrillation induced after isthmus ablation. Typical flutter waves appeared following the 5th atrial fibrillatory cycle. B: Intracardiac electrograms during the AFL-like tachycardia. A regular atrial rhythm with a cycle length of 232 ms was recorded in a CCW activation sequence around the TA. Note the presence of apparent conduction delay between the atrial electrograms recorded at the adjacent Halo 7-8 and Halo 5-6 recording sites (bidirectional arrows), in the area of the ablated line shown in Figure 2A,B. Halo 21-22 to 1-2 = proximal to distal recording sites of the Halo catheter; HBE 3-4 and 1-2 = proximal and distal His-bundle electrograms; CS 8-9 to 1-2 = proximal and distal coronary sinus recordings.ical study, the clinical tachycardia developed spontaneously, following atrial fibrillation induced by bursts of rapid atrial pacing. On the 12-lead electrocardiogram recorded during the tachycardia the flutter wave was positive in leads II, III, aV F , V 5 , and V 6 , and negative in lead V 1 . No other atrial tachyarrhythmia was inducible by any standard method of induction. The atrial activation sequence along the TA during ongoing tachycardia, combined with entrainment pacing along the TA, confirmed the presence of typical clockwise (CW) AFL. Linear RF ablation blocked conduction across the IVC-TA isthmus, terminated the AFL and restored sinus rhythm. After confirmation of bidirectional block through the isthmus by differential pacing, a new tachycardia developed reproducibly following atrial fibrillation induced by bursts of rapid atrial pacing (Fig. 1A). On the 12-lead electrocardiogram recorded during the tachycardia, (a) the flutter wave was negative in leads II, III, aV F, V 5 , and V 6 , and positive in V 1 and V 2 (Fig. 1A), and (b) the atrial activation sequence along the TA during ongoing tachycardia was counterclockwise (CCW), similar to the recording during typical CCW

show abstract

Incremental Pacing for the Diagnosis of Complete Cavotricuspid Isthmus Block During Radiofrequency Ablation of Atrial Flutter

Abstract: Incremental pacing distinguishes complete CTI block from persistent conduction. Such identification, accompanied by additional ablation to achieve block, should minimize flutter recurrences after ablative therapy.

Cited by 24 publications

References 22 publications

Obstructive Sleep Apnea in Patients With Typical Atrial Flutter

Obstructive Sleep Apnea in Patients With Typical Atrial Flutter

Slow Conduction or Block of the Cavotricuspid Isthmus—Treat or Trick?

Atrial Flutter After Cavotricuspid Isthmus Ablation: What is the Mechanism?

Contact Info

Product

Resources

About