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Electrocardiographic Approach to Atrial Flutter: Classifications and Differential Diagnosis. Card Electrophysiol Clin 2022; 14:385-399. [PMID: 36153121 DOI: 10.1016/j.ccep.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Atrial flutter (AFL) is a macro-reentrant arrhythmia characterized, in a 12 lead ECG, by the continuous oscillation of the isoelectric line in at least one lead. In the typical form of AFL, the oscillation is most obvious in the inferior leads, due to a macro-reentrant circuit localized in the right atrium, with the cavo-tricuspid isthmus as a critical zone.: This circuit can be activated in a counterclockwise or clockwise direction generating in II, III, and aVF leads, respectively, a slow descending/fast ascending F wave pattern (common form of typical AFL) or a balanced ascending/descending waveform (uncommon form of typical AFL). Atypical AFLs (scar-related) do not include the CTI in the circuit and show an extremely variable circuit location and ECG morphology.
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Valeri Y, Bagliani G, Compagnucci P, Volpato G, Cipolletta L, Parisi Q, Misiani A, Fogante M, Molini S, Dello Russo A, Casella M. Pathophysiology of Typical Atrial Flutter. Card Electrophysiol Clin 2022; 14:401-409. [PMID: 36153122 DOI: 10.1016/j.ccep.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Nowadays, the pathophysiology mechanism of initiation and maintenance of reentrant arrhythmias, including atrial flutter, is well characterized. However, the anatomic and functional elements of the macro reentrant arrhythmias are not always well defined. In this article, we illustrate the anatomic structures that delineate the typical atrial flutter circuit, both clockwise and counterclockwise, paying attention to the inferior vena cava-tricuspid isthmus (CTI) and crista terminalis crucial role. Finally, we describe the left atrial role during typical atrial flutter, electrophysiologically a by-stander but essential in the phenotypic electrocardiogram (ECG).
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Affiliation(s)
- Yari Valeri
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy.
| | - Giuseppe Bagliani
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Quintino Parisi
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Agostino Misiani
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Marco Fogante
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Silvano Molini
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
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Liu H, Gu Z, Zhu C, Li M, Jiao J, Chen H, Yang G, Ju W, Gu K, Zhang F, Chen LY, Yang D, Chen M. ECG Predictors for New-Onset Atrial Fibrillation Within a Year After Radiofrequency Ablation of Counterclockwise-Rotating Atrial Flutter. Front Cardiovasc Med 2021; 8:739350. [PMID: 34869644 PMCID: PMC8632776 DOI: 10.3389/fcvm.2021.739350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 10/11/2021] [Indexed: 11/24/2022] Open
Abstract
Background: New-onset atrial fibrillation (AF) after ablation of typical atrial flutter (AFL) is not rare. This study aimed to investigate the predictive value of electrocardiographic parameters on new-onset AF post-typical AFL ablation. Methods: A total of 158 consecutive patients (79.1% males, mean age 57.8 ± 14.3 years) with typical AFL were enrolled between January 2012 and August 2017 in this single-center study. Patients with a history of AF before ablation were excluded. ECGs during sinus rhythm (SR) and AFL were collected. The duration of the negative component of flutter wave in lead II (DFNII), proportion of the DFNII of the total circle length of AFL (DFNII%), amplitude of the negative component of flutter wave in lead II (AFNII), duration (DPNV1), and amplitude (APNV1) of negative component of the P wave in lead V1, and P wave duration in lead II (DPII) during sinus rhythm were measured. Results: During a median follow-up of 26.9 ± 11.8 months, 22 cases (13.9%) developed new-onset AF. DFNII was significantly longer in patients with new-onset AF compared to patients without AF (114.7 ± 29.6 ms vs. 82.7 ± 12.8 ms, p < 0.0001). AFNII was significantly lower (0.118 ± 0.034 mV vs. 0.168 ± 0.051 mV, p < 0.0001), DPII (144.21 ± 23.77 ms vs. 111.46 ± 14.19 ms, p < 0.0001), and DPNV1 was significantly longer (81.07 ± 16.87 ms vs. 59.86 ± 14.42 ms, p < 0.0001) in patients with new-onset AF. In the multivariate analysis, DFNII [odds ratio (OR), 1.428; 95% CI, 1.039–1.962; p = 0.028] and DPII (OR, 1.429; 95% CI, 1.046–1.953; p = 0.025) were found to be independently associated with new-onset AF after typical AFL ablation. Conclusion: Parameters representing left atrial activation time under both the SR and AFL were independently associated with new-onset AF post-typical AFL ablation and may be useful in risk prediction, which needs to be confirmed by further prospective studies.
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Affiliation(s)
- Hailei Liu
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhoushan Gu
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chao Zhu
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mingfang Li
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jincheng Jiao
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongwu Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Yang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weizhu Ju
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kai Gu
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fengxiang Zhang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lin Yee Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Di Yang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Komaki T, Ogawa M, Idemoto Y, Morii J, Saku K, Miura S. Gap-related Pulmonary Vein and Left Atrial Flutter Mimicking Cavotricuspid Isthmus-dependent Atrial Flutter. Intern Med 2020; 59:1413-1416. [PMID: 32132334 PMCID: PMC7332630 DOI: 10.2169/internalmedicine.4079-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report a 79-year-old man with recurrent atrial flutter (AFL) following catheter ablation for pulmonary vein (PV) isolation and block line of the cavotricuspid isthmus. An electrophysiological study and three-dimensional mapping results revealed left atrium (LA)-PV macroreentrant flutter caused by a conduction gap, possibly correlated to prior application, which mimicked cavotricuspid isthmus-dependent AFL. This LA-PV flutter was terminated after applying radiofrequency to the gap at the antrum near the bottom left inferior PV in the posterior LA wall. During follow-up, the patient did not present with atrial tachyarrhythmias; antiarrhythmic drugs were therefore not administered.
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Affiliation(s)
- Tomo Komaki
- Department of Cardiology, Fukuoka University School of Medicine, Japan
| | - Masahiro Ogawa
- Department of Cardiology, Fukuoka University School of Medicine, Japan
- Endowed Department of Advanced Therapeutics for Cardiovascular Disease, Fukuoka University, Japan
- Endowed Department of Future Medicine for Cardiovascular Disease, Fukuoka University, Japan
| | - Yoshiaki Idemoto
- Department of Cardiology, Fukuoka University School of Medicine, Japan
- Endowed Department of Advanced Therapeutics for Cardiovascular Disease, Fukuoka University, Japan
| | - Joji Morii
- Department of Cardiology, Fukuoka University School of Medicine, Japan
| | - Keijiro Saku
- Department of Cardiology, Fukuoka University School of Medicine, Japan
- Endowed Department of Advanced Therapeutics for Cardiovascular Disease, Fukuoka University, Japan
- Endowed Department of Future Medicine for Cardiovascular Disease, Fukuoka University, Japan
| | - Shinichiro Miura
- Department of Cardiology, Fukuoka University School of Medicine, Japan
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De Sisti A, Andronache M, Damiano P, Eschalier R, Font M. Is proximal coronary sinus involved in the circuit in some cases of ECG "typical" atrial flutter? J Cardiovasc Electrophysiol 2018; 29:1508-1514. [PMID: 30080278 DOI: 10.1111/jce.13703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 07/19/2018] [Accepted: 07/24/2018] [Indexed: 11/29/2022]
Abstract
AIM It is commonly conceived that coronary sinus (CS) participates in atrial flutter (AFL) circuit but limited to the fibers surrounding its ostium. We evaluated the involvement of proximal CS in typical AFL. METHODS Twenty AFL patients underwent entrainment mapping using postpacing interval minus AFL cycle length (PPI-AFL CL) including CS where a decapolar catheter was positioned with proximal bipole 1 cm from the ostium. RESULTS We compared patients with proximal CS within the circuit (group 1, PPI-AFL CL ≤ 20 ms + concealed entrainment) and those without (group 2, PPI-AFL CL > 20 ms). Group 1 patients were older, 77.5 ± 4 vs 71 ± 12 years (P < 0.05). No difference was found in AFL CL, PPI-AFL CL at cavotricuspid isthmus (CTI) entry, plateau, and septal site. Group 1 patients had shorter PPI-AFL CL at proximal CS (9 ± 3 vs 40 ± 15 ms; P < 0.001) and fragmented mesodiastolic CS atrial potentials (APs) (106 ± 27 vs 58.5 ± 22 ms; P < 0.001). A mid-septal unexcitable scar was found in five of eight group 1 patients vs one of 12 group 2 patients (P < 0.05). All were ablated at CTI. A patient had AFL recurrence and underwent a second attempt: PPI-AFL CL was 60 ms at CTI entry and less than or equal to 20 ms at septal CTI and proximal CS; AFL was terminated 1 cm inside CS, applying RF at a fragmented AP. CONCLUSION Proximal CS appears to be involved in a substantial subset of typical AFL patients, in whom advanced age, fragmented CS APs, and the presence of right atrial scar are prevalent. Proximal CS might be considered as an un-"innocent by-stander," but able, in rare cases, to generate a second AFL circuit.
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Affiliation(s)
- Antonio De Sisti
- Rhythmology Unit, Cardiology Department, Henry Mondor Hospital, Aurillac, France
| | - Marius Andronache
- Rhythmology Unit, Cardiology Department, University Hospital Center, Clermont-Ferrand, France
| | - Pamela Damiano
- Rhythmology Unit, Cardiology Department, Henry Mondor Hospital, Aurillac, France
| | - Roman Eschalier
- Rhythmology Unit, Cardiology Department, University Hospital Center, Clermont-Ferrand, France
| | - Manuel Font
- Rhythmology Unit, Cardiology Department, Henry Mondor Hospital, Aurillac, France
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6
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Shen MJ, Knight BP, Kim SS. Fusion during entrainment at the cavotricuspid isthmus: What is the mechanism? Heart Rhythm 2018; 15:787-789. [PMID: 29709230 DOI: 10.1016/j.hrthm.2017.12.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Mark J Shen
- Division of Cardiology, Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Bradley P Knight
- Division of Cardiology, Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Susan S Kim
- Division of Cardiology, Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
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Ota M, Kaneko Y, Nakajima T, Irie T, Iijima T, Saito A, Kurabayashi M. Detection of sequential activation of left atrium and coronary sinus musculature in the general population. J Arrhythm 2016; 32:449-455. [PMID: 27920828 PMCID: PMC5129123 DOI: 10.1016/j.joa.2016.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/19/2016] [Accepted: 02/03/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The direction of impulse propagation across the coronary sinus (CS) musculature (CSM) is an important piece of the mechanistic puzzle underlying atrial tachyarrhythmias. We hypothesized that in the general population, the sequence of left atrial (LA) to CSM electrograms recorded in the CS reflects the direction of impulse propagation over the CSM. METHODS We studied 19 patients with atrioventricular (AV) reentrant tachycardia (RT) utilizing a left-sided accessory pathway (AP) and 21 patients with typical counterclockwise atrial flutter (AFL). Conduction through the CSM during AVRT and AFL is from the left atrial (LA) to the right atrial (RA) and from the RA to LA direction, respectively. CS recordings of retrograde conduction over the AP and of AFL were analyzed in search of far-field, LA potentials. RESULTS Among 19 patients with AP, LA potentials were visible in 7 (37%), all in an LA → CSM activation sequence, while among the 21 patients with AFL, LA potentials were visible in 14 (67%), all in a CSM-LA activation sequence (P<0.0001). The prevalence of LA potentials was similar between both study groups (P=0.1119), and the overall prevalence was 53%. CONCLUSIONS Far-field LA potentials are often recorded in the CS during sequential LA and CSM activation in the general population. The timing of LA potentials in CS recordings reflected the direction of conduction across the CSM.
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Affiliation(s)
- Masaki Ota
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Yoshiaki Kaneko
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Tadashi Nakajima
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Tadanobu Irie
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Takafumi Iijima
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Akihiro Saito
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
| | - Masahiko Kurabayashi
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
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8
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Nakanishi T, Fukuzawa K, Yoshida A, Itoh M, Imamura K, Fujiwara R, Suzuki A, Yamashita S, Matsumoto A, Konishi H, Ichibori H, Hirata KI. Crista Terminalis as the Anterior Pathway of Typical Atrial Flutter: Insights from Entrainment Map with 3D Intracardiac Ultrasound. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:608-16. [PMID: 25644937 DOI: 10.1111/pace.12597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 12/25/2014] [Accepted: 01/12/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND The precise location of truly active reentry circuits of typical atrial flutter (AFL) has not been well identified. The purpose of this study was to verify our hypothesis that the posterior block line is located along the posteromedial right atrium (PMRA) and the crista terminalis (CT) is the anterior pathway of AFL, with real-time intracardiac echo (ICE). METHODS The entire right atrium (RA) three-dimensional activation and entrainment mapping were evaluated during AFL in 18 patients using CARTO sound. RESULTS The CT was clearly visualized by ICE and the local electrograms along the CT were single potentials in all the patients. The CT was recognized as the truly active anterior pathway based on entrainment mapping in all patients. Double potentials were recorded along the PMRA. Entire RA entrainment mapping could be performed in 16 patients. The reentry circuits were separated into three passages. The first was around the tricuspid annulus (TA), the second the anterior superior vena cava (SVC; AFL waves passed between the anterior SVC and RA appendage), and the last the posterior SVC (between the posterior SVC and upper limit of the PMRA). All three of these passages were active in four, around the TA and anterior SVC in eight, around the TA and posterior SVC in three, and around only the anterior SVC in one patient. CONCLUSIONS The CT functions as the anterior pathway of typical AFL, and the posterior block line was located along the PMRA. Dual or triple circuits were recognized in the majority of AFL patients.
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Affiliation(s)
- Tomoyuki Nakanishi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Eccentric activation of the coronary sinus during typical atrial flutter: What is the mechanism? J Arrhythm 2014. [DOI: 10.1016/j.joa.2014.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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10
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Sasaki K, Sasaki S, Kimura M, Owada S, Horiuchi D, Itoh T, Ishida Y, Okumura K. Revisit of typical counterclockwise atrial flutter wave in the ECG: electroanatomic studies on the determinants of the morphology. Pacing Clin Electrophysiol 2013; 36:978-87. [PMID: 23594189 DOI: 10.1111/pace.12129] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 01/25/2013] [Accepted: 01/31/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cavotricuspid isthmus-dependent counterclockwise atrial flutter (typical AFL) is characterized by negative saw-tooth morphology flutter wave (F-wave) in the inferior leads, which is classified as type 1 with purely negative F-wave without positive terminal deflection (PTD), type 2 with small PTD, and type 3 with broad PTD. The determinants of these morphological differences remain to be elucidated. METHODS AND RESULTS Of 72 patients (58 males, 65 ± 13 years) with typical AFL, 19 were classified as type 1 and 53 as types 2 and 3. We created an electroanatomic map of the right atrium (RA) during AFL and determined which RA site activation corresponded to which F-wave component by analyzing the activation map. It was revealed that F-wave component from the nadir to terminal deflection point coincided with the cranio-caudal activation of the RA free wall (RAFW) in all types. The bipolar voltage map showed that type 1 had the greater extent of low voltage (<0.5 mV) area (LVA) in RAFW (39 ± 24%) than types 2 and 3 (4 ± 3%) (P < 0.0001), explaining the absence of PTD in type 1. In types 2 and 3, F-wave amplitude determining the PTD magnitude was highly correlated with the longitudinal distance between two points on RAFW corresponding to the nadir and peak of F-wave (r = 0.73, P < 0.0001). CONCLUSIONS Terminal positivity and amplitude of F-wave in typical AFL are primarily related to the RAFW activity: negatively by the extent of LVA and positively by the longitudinal vector of activation.
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Affiliation(s)
- Kenichi Sasaki
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Jones AR, Krummen DE, Narayan SM. Non-invasive identification of stable rotors and focal sources for human atrial fibrillation: mechanistic classification of atrial fibrillation from the electrocardiogram. Europace 2013; 15:1249-58. [PMID: 23449925 DOI: 10.1093/europace/eut038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS To develop electrocardiogram (ECG) tools to quantify the number of sources for atrial fibrillation (AF), i.e. spatially stable rotors and focal impulses, and whether they lie in right or left atrium. Intracardiac mapping has recently shown that paroxysmal and persistent AF is sustained by rotors or focal sources that are stable in location and thus targets for limited ablation [focal impulse and rotor modulation (FIRM)] to eliminate AF. Importantly, the numbers and locations of concurrent sources determine both the complexity of AF and the approach for ablation. METHODS AND RESULTS In 36 AF patients (n = 29 persistent, 63 ± 9 years) in the CONventional ablation with or without Focal Impulse and Rotor Modulation (CONFIRM) trial, we developed phase lock (PL) to quantify spatial repeatability of ECG 'F-waves' between leads over time. Phase lock spectrally quantifies the angle θ between F-wave voltages in planes formed by ECG leads I, aVF, and V1 at successive points in time. We compared PL with ECG spectral dominant frequency (DF) and organizational index (OI) to characterize stable rotors and focal sources validated by intracardiac FIRM mapping. Focal impulse and rotor modulation ablation alone at ≤3 sources acutely terminated and rendered AF non-inducible or substantially slowed AF in 31 of 36 patients. Receiver operating characteristics of PL for this endpoint had area under the curve (AUC) = 0.72, and the optimum cut-point (PL = 0.09) had 74% sensitivity, 92% positive predictive value (PPV). Receiver operating characteristics areas for OI and DF were 0.50 and 0.58, respectively. Left (n = 28) or right (n = 3) atrial sources were localized by PL with AUC = 0.85, sensitivity 100%, PPV 30%, and negative predictive value 100%. Spectral DF provided AUC = 0.79. Notably, PL did not comigrate with diagnosis of paroxysmal or persistent AF (P = NS), unlike ECG DF. CONCLUSION The novel metric of ECG PL identifies patients with fewer (≤3) or greater numbers of stable rotors/focal sources for AF, validated by intracardiac FIRM mapping, and localized them to right or left atria. These data open the possibility of using 12-lead ECG analyses to classify AF mechanistically and plan procedures for right- or left-sided FIRM ablation.
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Affiliation(s)
- Aled R Jones
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
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12
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Mori S, Tada N, Sakurai M, Suzuki K, Takizawa K, Ootomo T, Mitsuoka M, Ito Y, Inoue N, Meguro T. Interatrial mechanical dyssynchrony shown by tissue doppler imaging during atrial flutter. JOURNAL OF CLINICAL ULTRASOUND : JCU 2012; 40:247-251. [PMID: 22434728 DOI: 10.1002/jcu.21905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 01/27/2012] [Indexed: 05/31/2023]
Abstract
Although regular supraventricular tachycardia is traditionally classified on the basis of P-wave morphology, diagnostic accuracy is limited to information obtained from surface electrocardiography. Intracardiac electrophysiology is a conclusive although invasive diagnostic method. We report a case of regular supraventricular tachycardia with a heart rate of 162 bpm. M-mode echocardiography of the interatrial septum clarified both the atrial rate and the ventricular response ratio. Tissue Doppler M-mode imaging demonstrated the delay between the posterior wall motion of the left and right atrium. Although it deserves further study, transthoracic echocardiography may provide useful information in addition to electrocardiography.
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Affiliation(s)
- Shumpei Mori
- Division of Cardiology, Cardiovascular Center, Sendai Kousei Hospital, Sendai, Miyagi, Japan
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13
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Clementy N, Pierre B, Fauchier L, Babuty D. Atrial flutter: Right, left, or both? Heart Rhythm 2012; 9:844-5. [DOI: 10.1016/j.hrthm.2010.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Indexed: 11/25/2022]
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14
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Buchta P, Sommer P, Polonski L, Gasior M, Hindricks G, Arya A. Changing coronary sinus activation during catheter ablation of isthmus-dependent right atrial flutter: what is the mechanism? Europace 2012; 14:912-4. [DOI: 10.1093/europace/eur397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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15
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Lau DH, Mackenzie L, Shipp NJ, Kuklik P, Dimitri H, Lobb BLW, Alasady M, Lim HS, Kelly DR, Brooks AG, Saint DA, Sanders P. Feasibility of high-density electrophysiological study using multiple-electrode array in isolated small animal atria. Clin Exp Pharmacol Physiol 2011; 37:1023-7. [PMID: 20659129 DOI: 10.1111/j.1440-1681.2010.05435.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
1. High-density cardiac electrophysiological study (EPS) of small animal atria has been limited to optical mapping techniques, which require complex and expensive equipment setup. We aim to evaluate the feasibility of carrying out EPS in isolated atrial tissues using a custom made high-density multiple-electrode array (MEA). 2. Isolated rat atrial preparations were studied. The MEA (4 × 5 mm) consisted of 90 silver chloride coated electrodes (0.1 mm diameter, 0.5 mm pitch) and was connected to a conventional EP system yielding 80 bipolar signals. Atrial tissues were placed over the MEA in a dish bubbled with 100% oxygen and superfused with modified HEPES solution at pH 7.35 and 37°C. Then, 1 mmol of 2,3-butanedione monoxime was added to suppress motion artifacts from muscle contractions. Custom plaque analysis software was used for offline conduction analysis. 3. Isolated atrial tissues showed good viability of > 30 min, allowing ample time for complete EPS. High quality electrograms with excellent signal to noise ratio were obtained. All electrophysiological parameters showed good reproducibility: effective refractory period, conduction velocity and heterogeneity index. Tachycardia was also inducible in these normal atria. 4. The present study shows the feasibility of performing high-density EPS of small isolated atrial tissues with a conventional electrode-based technique. The MEA system is compatible with standard electrophysiology recording systems and provides a novel, inexpensive option for detailed EPS in small animal models. In particular, it presents new research avenues to further explore the mechanisms of atrial arrhythmias in various transgenic and knockout rodent models.
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Affiliation(s)
- Dennis H Lau
- Cardiovascular Research Centre, Department of Cardiology, Royal Adelaide Hospital, Disciplines of Medicine and Physiology, University of Adelaide, Adelaide, Australia
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Dizon J, Biviano A, Whang W, Ehlert F, Garan H. Changes in low right atrial conduction times during pulmonary vein isolation for atrial fibrillation: correlation with inducibility of typical right atrial flutter. Europace 2011; 13:942-8. [PMID: 21427089 DOI: 10.1093/europace/eur033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Isthmus-dependent right atrial flutter (RAFL) is a common sequela of pulmonary vein isolation (PVI). It is unclear as to whether RAFL is a result of PVI or a concealed phenomenon unmasked by the elimination of atrial fibrillation (AF). We measured low right atrial conduction times (LRACTs) before and after PVI and examined their relationship to the inducibility of RAFL. METHODS AND RESULTS Twenty consecutive patients with paroxysmal AF but no history of RAFL were studied during the initial PVI procedure by radiofrequency ablation. Antiarrhythmic agents were discontinued for at least five half-lives. The clockwise and counterclockwise LRACTs were measured before and after PVI by pacing the proximal coronary sinus or low-lateral RA. Programmed atrial stimulation was performed post-PVI. Right atrial flutter, if inducible, was confirmed by entrainment mapping. Right atrial flutter was induced in six patients (Group A). No arrhythmias or only AF was induced in the remaining 14 patients (Group B). The average change in the clockwise LRACT was 19.8±17.5 ms in Group A vs. 0.3±10.7 ms in Group B (P<0.05). The average change in the counterclockwise LRACT was 25.7±30.4 ms in Group A vs. 0.0±6.7 ms in Group B (P<0.05). There were no significant differences between the groups in absolute LRACT or number of ablation lesions around the right pulmonary veins. CONCLUSION Right atrial flutter post-PVI is associated with prolongation of LRACTs. Ablation over the septal left atrium near the posterior right atrium during isolation of the right pulmonary veins may cause conduction delays that can lead to RAFL.
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Affiliation(s)
- José Dizon
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, Columbia University, 630 West. 168th Street, New York, NY 10032, USA.
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DIXIT SANJAY, LAVI NIMROD, ROBINSON MELISSA, RILEY MICHAELP, CALLANS DAVIDJ, MARCHLINSKI FRANCISE, LIN DAVID. Noncontact Electroanatomic Mapping to Characterize Typical Atrial Flutter: Participation of Right Atrial Posterior Wall in the Reentrant Circuit. J Cardiovasc Electrophysiol 2010; 22:422-30. [DOI: 10.1111/j.1540-8167.2010.01917.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Yang Y, Varma N, Badhwar N, Tanel RE, Sundara S, Lee RJ, Lee BK, Tseng ZH, Marcus GM, Kim AM, Olgin JE, Scheinman MM. Prospective observations in the clinical and electrophysiological characteristics of intra-isthmus reentry. J Cardiovasc Electrophysiol 2010; 21:1099-106. [PMID: 20455984 DOI: 10.1111/j.1540-8167.2010.01778.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Intra-isthmus reentry (IIR) is a circuit within the cavotricuspid isthmus (CTI). The purpose of this study is to prospectively define the electrogram and surface ECG characteristics of IIR, and its clinical implications. METHODS AND RESULTS Fourteen patients underwent electrophysiological studies and were found to have IIR. Detailed electrogram mapping of the CTI was available in all, electroanatomic mapping (EAM) in 8 of 14 (57%) patients. In all, entrainment mapping during tachycardia proved reentry, and showed that the anteroinferior CTI was out of the circuit and the septal CTI was in the circuit in 12 of 14 patients, whereas in 2, the circuit was confined within the mid and/or anteroinferior CTI. Fractionated potentials (FPs) spanning 34-71% of the tachycardia cycle length were recorded within the CTI in all, and double potentials were inscribed in 10 of 14 (71%). Analysis of the tricuspid annulus electrograms showed spontaneous shifts from a counterclockwise (CCW) to clockwise or fusion patterns. Surface ECGs showed either typical CCW pattern (12 patients) or atypical patterns (3 patients). The EAMs showed a focal pattern in 3, a CCW pattern in 5. The successful ablation site always occurred at the area with maximal FP duration. Over the same period, 33 of 384 (9%) patients who underwent ablation for CTI-dependent flutter had prior successful CTI ablation, 7 of 33 (21%) were found to have IIR during the redo procedure. CONCLUSIONS (1) Electrogram and ECG patterns of IIR frequently show atypical flutter. (2) IIR was successfully ablated in an area of the CTI associated with maximal duration of FPs. (3) IIR is a significant cause of "recurrent flutter" in patients with prior CTI ablation.
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Affiliation(s)
- Yanfei Yang
- University of California-San Francisco, San Francisco, California 94143-1354, USA
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Abstract
Cardiac arrhythmias are a major cause of death and disability. Despite the clinical need and the importance of studying arrhythmia mechanisms in humans, a noninvasive imaging modality for cardiac electrophysiology is not yet available for routine application. Here we describe such a noninvasive imaging modality, electrocardiographic imaging (ECGI), and provide examples of its application in various (normal and abnormal) cardiac rhythms.
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Affiliation(s)
- Yoram Rudy
- Cardiac Bioelectricity and Arrhythmia Center, Washington University in St. Louis, St. Louis, Missouri 63130, USA.
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Barbato G, Carinci V, Tomasi C, Frassineti V, Margheri M, Di Pasquale G. Is electrocardiography a reliable tool for identifying patients with isthmus-dependent atrial flutter? Europace 2009; 11:1071-6. [PMID: 19574262 DOI: 10.1093/europace/eup166] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gaetano Barbato
- Cardiology Department, Maggiore Hospital, Largo Nigrisoli 2, Bologna, Italy
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21
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Mechanisms of atypical flutter wave morphology in patients with isthmus-dependent atrial flutter. Heart Vessels 2009; 24:211-8. [DOI: 10.1007/s00380-008-1108-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Accepted: 08/14/2008] [Indexed: 10/20/2022]
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22
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Aiba T, Shimizu W, Noda T, Okamura H, Satomi K, Suyama K, Kurita T, Aihara N, Kamakura S. Noninvasive Characterization of Intra-Atrial Reentrant Tachyarrhythmias After Surgical Repair of Congenital Heart Diseases. Circ J 2009; 73:451-60. [DOI: 10.1253/circj.cj-08-0656] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takeshi Aiba
- Division of Cardiology, Department of Internal Medicine, National Cardiovascular Center
| | - Wataru Shimizu
- Division of Cardiology, Department of Internal Medicine, National Cardiovascular Center
| | - Takashi Noda
- Division of Cardiology, Department of Internal Medicine, National Cardiovascular Center
| | - Hideo Okamura
- Division of Cardiology, Department of Internal Medicine, National Cardiovascular Center
| | - Kazuhiro Satomi
- Division of Cardiology, Department of Internal Medicine, National Cardiovascular Center
| | - Kazuhiro Suyama
- Division of Cardiology, Department of Internal Medicine, National Cardiovascular Center
| | - Takashi Kurita
- Division of Cardiology, Department of Internal Medicine, National Cardiovascular Center
| | - Naohiko Aihara
- Division of Cardiology, Department of Internal Medicine, National Cardiovascular Center
| | - Shiro Kamakura
- Division of Cardiology, Department of Internal Medicine, National Cardiovascular Center
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FUKUZAWA KOJI, YOSHIDA AKIHIRO, KUBO SHINYA, TAKANO TAKATSUGU, KIUCHI KUNIHIKO, KANDA GAKU, TAKAMI KAORU, KUMAGAI HIROYUKI, TORII SATOKO, TAKAMI MITSURU, OHNISHI YOSHIO, OKAJIMA KATSUNORI, HIRATA KENICHI. Upper Turnover Portion of the Reentry Circuit for Typical and Reverse Typical Atrial Flutter. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:1160-7. [DOI: 10.1111/j.1540-8159.2008.01157.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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Narayan SM, Krummen DE. Dynamics factors preceding the initiation of atrial fibrillation in humans. Heart Rhythm 2008; 5:S22-5. [PMID: 18456196 DOI: 10.1016/j.hrthm.2008.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Indexed: 11/17/2022]
Affiliation(s)
- Sanjiv M Narayan
- University of California and Veterans Administration Medical Centers, San Diego, California, USA
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25
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Ashino S, Watanabe I, Okumura Y, Okubo K, Saito S. Change in atrial flutter wave morphology-insight into the sources of electrocardiographic variants in common atrial flutter. Pacing Clin Electrophysiol 2007; 30:1023-6. [PMID: 17669089 DOI: 10.1111/j.1540-8159.2007.00804.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Whether the activation sequence of the right or left atrium plays a role in the morphology of the flutter wave in common atrial flutter is not completely understood. We present two patients with common counterclockwise atrial flutter in whom changes in the left atrial activation sequence produced significant changes in flutter wave polarity (+ to - and - to -/+ biphasic) without a change in the activation sequence within the right atrium. These cases highlight the possible role of alterations of the interatrial connections in the genesis of atypical manifestations of common atrial flutter.
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Affiliation(s)
- Sonoko Ashino
- Department of Cardiovascular Disease, Nihon University School of Medicine, 30-1 Oyaguchi-Kami, Itabashi-Ku, Tokyo 173-8610, Japan
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26
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Lemery R, Birnie D, Tang ASL, Green M, Gollob M, Hendry M, Lau E. Normal Atrial Activation and Voltage During Sinus Rhythm in the Human Heart: An Endocardial and Epicardial Mapping Study in Patients with a History of Atrial Fibrillation. J Cardiovasc Electrophysiol 2007; 18:402-8. [PMID: 17394455 DOI: 10.1111/j.1540-8167.2007.00762.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The three-dimensional contributions to human atrial activation in sinus rhythm have not been specifically characterized. We evaluated the sequence of endocardial and epicardial activation and voltage of the atria during normal sinus rhythm. METHODS AND RESULTS The study group includes 35 patients with history of symptomatic atrial fibrillation. Prior to catheter ablation of atrial fibrillation, we performed multielectrode electroanatomic mapping during sinus rhythm, endocardially of the RA, LA, and coronary sinus (CS) and, in 10 patients, epicardially of the transverse sinus and oblique sinus. Following activation of the atrial region of the sinus node, the epicardial transverse sinus was activated 11 +/- 18 msec later, while the earliest endocardial LA activation occurred in the region of Bachmann's bundle at 31 +/- 13 msec, significantly earlier than the earliest epicardial LA activation of the oblique sinus at 54 +/- 10 msec (P < 0.002). The posterior LA revealed complex types of activation in 66% of patients analyzed, due to the convergence of wavefront propagation from the CS, oblique sinus, and endocardial LA. Bipolar voltage measurements revealed significantly higher values for the epicardium (mean 3.05 +/- 1.31 mv) than for the endocardium (mean 1.65 +/- 0.75 mv), P < 0.0001 between both groups. CONCLUSIONS In sinus rhythm, we have characterized endocardial and epicardial atrial activation and voltage, and provide an analysis and understanding of the genesis of the P wave complex in humans.
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Affiliation(s)
- Robert Lemery
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada.
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27
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Abstract
Repolarization abnormalities, including those induced by the congenital or acquired long QT (LQT) syndrome, provide a substrate for life-threatening cardiac arrhythmias. In this article, we use computational biology to link HERG mutations mechanistically to the resulting abnormalities of the whole-cell action potential. We study how the kinetic properties of I(Ks) (the slow delayed rectifier) that are conferred by molecular subunit interactions, facilitate its role in repolarization and 'repolarization reserve'. A new noninvasive imaging modality (electrocardiographic imaging) is shown to image cardiac repolarization on the epicardial surface, suggesting its possible role in risk stratification, diagnosis and treatment of LQT syndrome.
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Affiliation(s)
- Y Rudy
- Cardiac Bioelectricity and Arrhythmia Center (CBAC), Washington University in St Louis, St Louis, MO 63130-4899, USA.
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28
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Dong J, Zrenner B, Schreieck J, Deisenhofer I, Karch M, Schneider M, Von Bary C, Weyerbrock S, Yin Y, Schmitt C. Catheter ablation of left atrial focal tachycardia guided by electroanatomic mapping and new insights into interatrial electrical conduction. Heart Rhythm 2005; 2:578-91. [PMID: 15922263 DOI: 10.1016/j.hrthm.2005.03.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2005] [Accepted: 03/16/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND Experience in catheter ablation of left atrial (LA) focal tachycardia and information about interatrial electrical connections during LA focal tachycardia are limited. OBJECTIVES The purpose of this study was to describe our experience in electroanatomic mapping-guided catheter ablation of LA focal tachycardia and to investigate interatrial electrical connections during LA focal tachycardias. METHODS Thirty-three patients undergoing catheter ablation for LA focal tachycardia guided by electroanatomic mapping were reported. Interatrial electrical connections were analyzed in LA focal tachycardias with biatrial electroanatomic maps. RESULTS Of the 35 LA focal tachycardias (cycle length 309 +/- 100 ms) mapped, 19 (54%) originated from the pulmonary veins (PVs), 6 (17%) from the mitral annulus, 3 (8.6%) from LA roof, 3 (8.6%) from LA posterior wall, 2 (5.7%) from LA appendage, and 2 (5.7%) from LA septum. Fourteen of the 19 PV tachycardias (74%) were located in proximity to PV ostia. In 14 (7 PV, 7 non-PV) LA focal tachycardias with biatrial electroanatomic maps, posterior right atrium breakthrough sites at the intercaval area were identified in 7 PV tachycardias and 1 non-PV tachycardia. Five of the 7 PV tachycardias used only the posterior breakthrough for interatrial propagation. Procedural success was achieved in 33 of 35 LA focal tachycardias (94%) in 31 patients. During 23 +/- 19 months of follow-up, 2 patients (6%) had recurrence of ablated tachycardia, and 3 (10%) developed new LA focal tachycardias. CONCLUSIONS The PVs and the mitral annulus were the main sources of LA focal tachycardias. The majority of PV tachycardias originated from PV ostia. A posterior interatrial connection appeared to play a major role in interatrial electrical propagation during PV tachycardias. Electroanatomic mapping facilitated precise localization of LA focal tachycardias and achievement of a high rate of ablation success.
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Affiliation(s)
- Jun Dong
- The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-0409, USA.
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29
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Yuniadi Y, Tai CT, Lee KT, Huang BH, Lin YJ, Higa S, Liu TY, Huang JL, Lee PC, Chen SA. A new electrocardiographic algorithm to differentiate upper loop re-entry from reverse typical atrial flutter. J Am Coll Cardiol 2005; 46:524-8. [PMID: 16053969 DOI: 10.1016/j.jacc.2005.04.049] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Revised: 04/12/2005] [Accepted: 04/14/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study was performed to differentiate upper loop re-entry (ULR) from reverse typical atrial flutter (AFL). BACKGROUND Right atrial ULR and reverse typical AFL have different mechanisms and ablation strategies, but similar electrocardiographic characteristics. METHODS This study included 26 patients with reverse typical AFL and 20 patients with ULR. The noncontact mapping system (EnSite-3000, Endocardial Solutions, St. Paul, Minnesota) was used to confirm diagnosis and guide successful radiofrequency ablation. Flutter wave polarity and amplitude in the 12-lead surface electrocardiogram were determined by two independent electrophysiologists. RESULTS The flutter wave polarity in leads I and aVL was significantly different between the reverse typical AFL and ULR groups (p < or = 0.001). Voltage measurement revealed significant differences between reverse typical AFL and ULR in leads I, II, aVR, aVF, V1, and V2 (p < 0.001). A new diagnostic algorithm based on negative or isoelectric/flat flutter wave polarity and amplitude < or =0.07 mV in lead I was useful for diagnosis of ULR, with an accuracy of 90% to 97%, a sensitivity of 82% to 100%, and a specificity of 95%. CONCLUSIONS Polarity and voltage measurement of flutter wave in lead I can differentiate reverse typical AFL from ULR.
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Affiliation(s)
- Yoga Yuniadi
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, and National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
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Xia Y, Hertervig E, Kongstad O, Ljungström E, Platonov P, Pyotr P, Holm M, Olsson B, Yuan S. Deterioration of interatrial conduction in patients with paroxysmal atrial fibrillation: electroanatomic mapping of the right atrium and coronary sinus. Heart Rhythm 2005; 1:548-53. [PMID: 15851217 DOI: 10.1016/j.hrthm.2004.07.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2004] [Accepted: 07/14/2004] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this study was to analyze the velocities across the coronary sinus ostium (cross-CSo) and within the coronary sinus (intra-CS) in patients with and without paroxysmal atrial (AF) fibrillation and to estimate the interatrial conduction deterioration area in AF patients. BACKGROUND Interatrial conduction delay in AF patients has been reported. However, localization of the interatrial conduction delay still is not clear. METHODS Thirteen patients with paroxysmal AF and 10 control patients with AV nodal reentrant tachycardia or ectopic atrial tachycardia were enrolled in the study. Right atrial and CS mapping were performed using the CARTO electroanatomic mapping system during sinus rhythm and during distal CS pacing. The activation times and spatial distances of cross-CSo and intra-CS were measured between paired sites, from which the activation velocities of cross-CSo and intra-CS were obtained. RESULTS During sinus rhythm, the activation velocities of cross-CSo in the AF group (1.2 +/- 0.2 m/s) were significantly slower than those in the control group (2.9 +/- 1.6 m/s, P < .05). During distal CS pacing, the cross-CSo velocities of the AF group (1.0 +/- 0.5 m/s) also appeared slower than those in the control group (1.4 +/- 0.2 m/s, P = .07). However, no difference was found in intra-CS activation velocities between the two groups (2.8 +/- 1.9 vs 3.2 +/- 2.2 m/s and 1.5 +/- 0.3 vs 1.4 +/- 0.3 m/s, P > .05 during sinus rhythm and distal CS pacing, respectively). CONCLUSIONS Interatrial conduction at the posteroparaseptal region across the CS ostium was significantly slower in patients with paroxysmal AF than in control patients, further supporting the link between interatrial conduction deterioration and paroxysmal AF.
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Affiliation(s)
- Yunlong Xia
- Department of Cardiology, University Hospital, Lund, Sweden
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31
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Narayan SM, Hassankhani A, Feld GK, Bhargava V. Separating non-isthmus- from isthmus-dependent atrial flutter using wavefront variability. J Am Coll Cardiol 2005; 45:1269-79. [PMID: 15837261 DOI: 10.1016/j.jacc.2004.12.070] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2004] [Revised: 12/06/2004] [Accepted: 12/07/2004] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this study was to separate isthmus-dependent atrial flutter (IDAFL) from non-isthmus-dependent atrial flutter (NIDAFL) from the electrocardiogram (ECG) based on functional differences. BACKGROUND The ECG analyses of F-wave shape suboptimally separate NIDAFL from IDAFL. The authors hypothesized that anatomic and functional differences may result in greater wavefront variability in NIDAFL than IDAFL, allowing their separation. The authors tested this hypothesis in patients undergoing ablation for atrial flutter using a novel ECG algorithm to detect subtle F-wave variability, validated by intracardiac measurements. METHODS In 62 patients (23 NIDAFL, 39 IDAFL) ECG atrial wavefronts were represented as correlations of an F-wave template to the ECG over time. Correlations in orthogonal ECG lead-pairs were plotted at each time point to yield loops reflecting temporal and spatial regularity in each plane. The ECG analyses were compared with intracardiac standard deviations of: 1) atrial electrograms (temporal variability), and 2) bi-atrial activation time differences (spatial variability). RESULTS Atrial ECG temporospatial loops were reproducible in IDAFL, but varied in NIDAFL (p < 0.01) suggesting greater variability that correctly classified IDAFL (39 of 39 cases) from NIDAFL (22 of 23 cases; p < 0.001). Intra-atrial mapping confirmed greater temporal variability for NIDAFL versus IDAFL, in lateral (p < 0.01) and septal (p = 0.03) right atrium, and proximal (p = 0.02) and distal (p < 0.01) coronary sinus. Spatial variability was greater in NIDAFL than IDAFL (p = 0.02). CONCLUSIONS Greater cycle-to-cycle atrial wavefront variability separates NIDAFL from IDAFL and is detectable from the ECG using temporospatial analyses. These results have implications for guiding ablation and support the concept that IDAFL and NIDAFL lie along a spectrum of intracardiac organization.
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Affiliation(s)
- Sanjiv M Narayan
- University of California and Veterans Administration Medical Centers, San Diego, California 92161, USA.
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Rotter M, Scavée C, Sacher F, Sanders P, Takahashi Y, Hsu LF, Rostock T, Hocini M, Jaïs P, Clementy J, Haïssaguerre M. Correlation of atrial electrocardiographic amplitude with radiofrequency energy required to ablate cavotricuspid isthmus-dependent atrial flutter. Heart Rhythm 2005; 2:263-9. [PMID: 15851316 DOI: 10.1016/j.hrthm.2004.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2004] [Accepted: 12/13/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate a possible correlation between atrial ECG amplitude in common atrial flutter (AFL) and radiofrequency (RF) energy required to achieve cavotricuspid isthmus block. BACKGROUND The amount of RF delivery required for ablation of typical AFL is variable. This variation has been attributed to the cavotricuspid isthmus anatomy. Atrial ECG amplitude can be a marker of atrial anatomic variations and therefore may correlate with RF duration required to achieve cavotricuspid isthmus block. METHODS Seventy consecutive patients were prospectively studied. Ablation of the cavotricuspid isthmus was performed by creating a line of block between the inferior tricuspid annulus and the inferior caval vein using 8-mm-tip electrode catheters. If more than 20 minutes of RF time was required to achieve conduction block, the catheter was changed to an irrigated-tip catheter. Atrial ECG amplitude was assessed in leads II, III, aVF, and aVL. RESULTS A total of 14 +/- 11 minutes of RF energy was delivered to achieve block in all patients; 12 patients (8%) required more than 20 minutes. Atrial ECG amplitude showed highly significant correlations with cumulative RF energy (F and P waves in lead II: r = 0.703 and r = 0.737, P < .001). P-wave amplitude <0.2 mV and/or flutter wave amplitude <0.35 mV in lead II have a high negative predictive value to predict <20 min RF delivery (96% and 89% respectively). CONCLUSIONS A significant correlation exists between atrial ECG amplitude and amount of RF required to ablate typical AFL. Atrial ECG amplitude may be a surrogate marker of characteristics of isthmus anatomy. These findings may influence the choice of catheter used for cavotricuspid isthmus ablation.
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Affiliation(s)
- Martin Rotter
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux 2, France.
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Dong J, Zrenner B, Schreieck J, Schmitt C. Necessity for Biatrial Ablation to Achieve Bidirectional Cavotricuspid Isthmus Conduction Block in a Patient Following Senning Operation. J Cardiovasc Electrophysiol 2004; 15:945-9. [PMID: 15333093 DOI: 10.1046/j.1540-8167.2004.03628.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the case of a 28-year-old male patient with a 17-year history of recurrent symptomatic atrial tachyarrhythmia following Senning operation for transposition of the great arteries. Biatrial electroanatomic mapping and entrainment mapping revealed counterclockwise peri-tricuspid annulus reentry in which cavotricuspid isthmus tissue in both systemic and pulmonary venous atria was involved. Linear ablation of the cavotricuspid isthmus in the pulmonary venous atrium terminated the tachycardia but did not block the isthmus conduction, and the tachycardia was reinduced. Bidirectional isthmus conduction block could be achieved only after additional linear ablation targeting the cavotricuspid isthmus tissue in the systemic venous atrium. We conclude that biatrial ablation may be necessary in order to achieve bidirectional isthmus block and prevent tachycardia recurrence in some patients following Senning or Mustard operation.
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Affiliation(s)
- Jun Dong
- Deutsches Herzzentrum München and 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
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Ramanathan C, Ghanem RN, Jia P, Ryu K, Rudy Y. Noninvasive electrocardiographic imaging for cardiac electrophysiology and arrhythmia. Nat Med 2004; 10:422-8. [PMID: 15034569 PMCID: PMC1950745 DOI: 10.1038/nm1011] [Citation(s) in RCA: 404] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2003] [Accepted: 02/20/2004] [Indexed: 11/08/2022]
Abstract
Over 7 million people worldwide die annually from erratic heart rhythms (cardiac arrhythmias), and many more are disabled. Yet there is no imaging modality to identify patients at risk, provide accurate diagnosis and guide therapy. Standard diagnostic techniques such as the electrocardiogram (ECG) provide only low-resolution projections of cardiac electrical activity on the body surface. Here we demonstrate the successful application in humans of a new imaging modality called electrocardiographic imaging (ECGI), which noninvasively images cardiac electrical activity in the heart. In ECGI, a multielectrode vest records 224 body-surface electrocardiograms; electrical potentials, electrograms and isochrones are then reconstructed on the heart's surface using geometrical information from computed tomography (CT) and a mathematical algorithm. We provide examples of ECGI application during atrial and ventricular activation and ventricular repolarization in (i) normal heart (ii) heart with a conduction disorder (right bundle branch block) (iii) focal activation initiated by right or left ventricular pacing, and (iv) atrial flutter.
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Affiliation(s)
- Charulatha Ramanathan
- Cardiac Bioelectricity Research and Training Center, and Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio 44106-7207, USA
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Abstract
The introduction of programmed electrical stimulation of the heart and intracardiac activation mapping 35 years ago made it possible to study the site of origin or the pathway of a supraventricular tachycardia and to obtain insight into the mechanism of the tachycardia. Information from these studies has been the basis for the development of new therapies, such as arrhythmia surgery, antitachycardia pacing, and catheter ablation. Correlation of intracardiac findings with the 12-lead ECG recorded during the tachycardia resulted in the recognition of ECG patterns characteristic of the different types of supraventricular tachycardias. Currently, gross localization of the site of origin of the arrhythmia is based on the 12-lead ECG recorded during the arrhythmia, with fine-tuning using intracardiac activation mapping and pacing. These developments during the past 3 decades have made accurate arrhythmia diagnosis possible and allow us to offer curative therapies to many of our patients with a supraventricular tachycardia.
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Affiliation(s)
- Hein J J Wellens
- Interuniversity Cardiology Institute of The Netherlands, Utrecht, The Netherlands.
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Abstract
The introduction of programmed electrical stimulation of the heart and intracardiac activation mapping 35 years ago made it possible to study the site of origin or pathway of a supraventricular tachycardia and to gain insight into the tachycardic mechanism. Information from these studies has been the basis for the development of new therapies, like arrhythmia surgery, antitachycardia pacing, and catheter ablation. The correlation of intracardiac findings with the 12-lead ECG during the tachycardia resulted in the recognition of characteristic ECG patterns for the different types of supraventricular tachycardias. Currently, gross localization of the site of origin of the arrhythmia is based on the 12-lead ECG during the arrhythmia with fine tuning using intracardiac activation mapping and pacing. These developments during the past 3 decades make accurate arrhythmia diagnosis possible and allow us to offer curative therapies to many of patients suffering from a supraventricular tachycardia.
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Affiliation(s)
- Hein J J Wellens
- Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands.
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