Incisional and nonincisional atrial macroreentry tachycardia in adult patients.
Causes, mapping, and long-term results of catheter ablation

Česká verzia

Authors: M. Fiala ^1,2; J. Chovančík ¹; P. Heinc ²; R. Neuwirth ¹; I. Nykl ¹; R. Nevřalová ¹; M. Branny ¹
Authors place of work: Kardiocentrum Nemocnice Podlesí, Třinec, přednosta prim MUDr. Marian Branny ¹; I. interní klinika Lékařské fakulty UP a FN, Olomouc, přednosta prof. MUDr. Jan Lukl, CSc. ²
Published in the journal: Vnitř Lék 2005; 51(11): 1236-1247
Category: Original Contributions

Summary

Atrial macroreentry tachycardias (AMRT) independent of the conduction across the subeustachian isthmus represent a relatively rare group of different reentry circuits developing from individual arrhytmogenic substrates.

The purpose of the study is to present causes, mapping facilities, and the results of catheter ablation of these arrhythmias.

Patients and methods:
Forty-two patients (11 females), aged 57.2 ± 12.8 years, presenting with clinically significant AMRT, were referred to mapping and catheter ablation. Eighteen patients had known structural heart disease, in other 24 patients, no significant structural heart disease could be detected. Electroanatomic mapping was used in 33 (67 %) of 49 ablation procedures.

Results:
In 49 ablation procedures, 59 critical isthmuses were targeted and 70 morphologies of 61 rates of mappable AMRT were eliminated. Fifty-six AMRT morphologies (41 in the right atrium and 15 in the left atrium) of 49 rates (35 in the right atrium and 14 in the left atrium) were eliminated with linear radiofrequency (RF) lesion. Fourteen AMRT morphologies of 12 rates (in the right atrium) were eliminated with focal lesion. Type I atrial flutter was also ablated in 20 patients. Anatomical approach using linear lesions for unmappable AMRT was simultaneously employed in six of the patients. Immediately at the end of the last ablation procedure, noninducibility of any AMRT was achieved in 37 (88 %) patients; in 31 (97 %) of 32 patients with right AMRT, and in 6 (60 %) of 10 patients with left AMRT. During long-term follow- up of 34 ± 24.7 months, AMRT did not recur in 39 (93 %) patients. Seven (17 %) patients had paroxysmal atrial fibrillation in the postablation period.

Conclusion:
AMRT can occur as a result of different cardiopathies as well as without association with any significant heart disease, typically in multiple morphologies and rates. Anatomy of the atria and the propagation of the electric impulse during AMRT can be truly electroanatomically reconstructed and AMRT can be eliminated by focal or linear lesion with high success rate. Long-term outcome of catheter ablation is favorable and propensity to the atrial fibrillation is low.

Key words:
atrial macroreentry tachycardia – conventional mapping – electroanatomic mapping – catheter ablation

Zdroje

1. Baker BM, Lindsay BD, Bromberg BI et al. Catheter ablation of clinical intraatrial reentrant tachycardias resulting from previous atrial surgery: localizing and transecting the critical isthmus. J Am Coll Cardiol 1996; 28: 411-417.

2. Gepstein L, Hayam G, Ben-Haim SA. A novel method for nonfluoroscopic catheter-based electroanatomical mapping of the heart: in vitro and in vivo accuracy results. Circulation 1997; 95: 1611-1612.

3. Chinitz LA, Bernstein NE, O´Connor B et al. Mapping reentry around atriotomy scars using double potentials. Pacing Clin Electrophysiol 1996; 19: 1978-1983.

4. Delacretaz E, Ganz LI, Soejima K et al. Multi atrial macro-re-entry circuits in adults with repaired congenital heart disease: entrainment mapping combined with three-dimensional electroanatomic mapping. J Am Coll Cardiol 2001; 37: 1665-1676.

5. Duru F, Hindricks G, Kottkamp H. Atypical left atrial flutter after intraoperative radiofrequency ablation of chronic atrial fibrillation: successful ablation using three-dimensional electroanatomic mapping. J Cardiovasc Electrophysiol 2001; 12: 602-605.

6. Fiala M, Heinc P, Lukl J. Katétrová ablace síňových tachyarytmií: Síňová tachykardie, flutter síní, fibrilace síní. Kardiologická revue 1999; 1(4): 215-223.

7. Fiala M, Heinc P, Lukl J. Radiofrequency catheter ablation of right atrial reentry tachycardia: multiple arrhythmogenic substrate does not prevent technical feasibility and long-term benefit using conventional mapping technique. Cor Vasa 2000; 42: 438-442.

8. Iesaka Y, Takahashi A, Goya M et al. Nonlinear ablation targeting an isthmus of critically slow conduction detected by high density electroanatomical mapping for atypical atrial flutter. Pacing Clin Electrophysiol 2000; 23: 1911-1915.

9. Jaïs P, Shah DC, Haïssaguere M et al. Mapping and ablation of left atrial flutters. Circulation 2000; 101: 2928-2934.

10. Kall JG, Rubenstein DS, Kopp DE et al. Atypical atrial flutter originating in the right atrial free wall. Circulation 2000; 101: 270-279.

11. Kalman JM, Van Hare GF, Olgin JE et al. Ablation of “incisional” reentrant atrial tachycardia complicating surgery for congenital heart disease: use of entrainment to define a critical isthmus of conduction. Circulation 1996; 93: 502-512.

12. Kalman JM, Olgin JE, Saxon LA et al. Electrocardiographic and electrophysiologic characterization of atypical atrial flutter in man. J Cardiovasc Electrophysiol 1997; 8: 121-144.

13. Lai LP, Lin JL, Tseng CD et al. Electropysiologic study and radiofreqeucny catheter ablation of isthmus-independent atrial flutter. J Cardiovasc Electrophysiol 1999; 10: 728-735.

14. Nakagawa H, Shah N, Matsudaira K et al. Characterization of reentrant circuit in acroreentrant right atrial tachycardia after surgical repair of congenital heart disease: isolated channels between scars allow “focal” ablation. Circulation 2001; 103: 699-709.

15. Ouyang F, Ernst S, Vogtmann T et al. Characterization of reentrant circuits in left atrial macroreentrant tachycardia: critical isthmus block can prevent atrial tachycardia recurrence. Circulation 2002; 105: 1934-1942.

16. Saoudi N, Cosio F, Waldo A et al. Classification of atrial flutter and regular atrial tachycardia according to electrophysiologic mechanism and anatomic bases: A statement from a joint expert group from the working group of arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. J Cardiovasc Electrophysiol 2001; 12: 852-866.

17. Stevenson WG, Sager PT, Friedman PL. Entrainment techniques for mapping atrial and ventricular tachycardias. J Cardiovasc Electrophysiol 1995; 6: 201-216.

18. Thomas SP, Nunn GR, Nicholson IA et al. Mechanism, localization and cure of atrial arrhythmias occurring after a new intraoperative endocardial radiofrequency ablation procedure for atrial fibrillation. J Am Coll Cardiol 2000; 35: 442-450.

19. Triedman JK, Bergau DM, Saul JP et al. Efficacy of radiofrequency ablation for control of intraatrial reentrant tachycardia in patients with congenital heart disease. J Am Coll Cardiol 1997; 30: 1032-1038.

20. Yang Y, Cheng J, Bochoeyer A et al. Atypical right atrial flutter patterns. Circulation 2001; 103: 3092-3098.