Narrow, Slow-Conducting Isthmus Dependent Left Atrial Reentry Developing After Ablation for Atrial Fibrillation: ECG Characterization and Elimination by Focal RF Ablation

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Abstract

Introduction

The complete circuit of reentrant left atrial tachycardias (LATs) occurring after ablation for atrial fibrillation (AF) has not been well described. Identifying discrete isthmuses critical to these LATs may simplify their elimination by catheter ablation.

Methods and Results

Fifteen patients (all male, 56 ± 8 years) with 15 reentrant LATs following AF ablation underwent activation and entrainment mapping. Eleven patients (11 LATs) had a single localized site with low amplitude (0.16 ± 0.05 mV), fractionated long duration (131 ± 23 msec) electrograms coinciding with an isoelectric interval of 106 ± 24 msec between flutter waves on all 12 ECG leads. Three-dimensional mapping and entrainment revealed this site to be a narrow markedly slowly conducting isthmus adjacent to ablated left (n = 8) or right (n = 3) pulmonary vein (PV) ostia, and critical to nine small diameter (15 ± 3 mm) and two large diameter (49 ± 2 mm) circuits. One radiofrequency (RF) application on this isthmus eliminated LAT in all 11 patients. Four patients (four LATs) with large circuits around the mitral annulus and/or PV ostia lacked isoelectric ECG intervals and slow-conducting isthmuses and required multiple RF applications across anatomically wide, rapidly conducting isthmuses.

Conclusion

Focally ablatable narrow isthmuses of slow conduction are critical for the majority of reentrant LAT occurring after ablation for AF. The role and presence of these isthmuses can be anticipated by observing significant isoelectric intervals between flutter waves on all 12-surface ECG leads. Their distinctive electrophysiological characteristics allow their identification and elimination by simple RF ablation.

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