Circumferential reentrant pulmonary vein tachycardia - an unusual cause of left atrial “flutter”

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A 46 year old man presented with recurrent symptomatic persistent atrial tachycardia (AT) four months after circumferential periostial pulmonary vein (PV) isolation for atrial fibrillation (AF). An out-patient ECG during tachycardiaand and on the day of ablation showed atrial tachycardia with cycle length of 273 ms and 2:1 AV conduction block. At electrophysiology study no diastolic or pre-systolic activation could be found in the RA, so a 15mm circumferential decapolar catheter was placed in the right superior (RS) PV via a transseptally placed sheath. This showed macroreentry in the RSPV with a cycle length of 144 ms that was completely mapped as a circumferential reentrant circuit with 2:1 conduction to the LA (Figure). The exit point to the LA demonstrated fusion of PV potentials to LA potentials (small arrows on figure) at PV 3–4. A single application of RF energy at PV 3–4 ablated the RSPV to LA connection with restoration of sinus rhythm in the LA and RA, without disrupting RSPV tachycardia. A single further application of RF energy at PV DS/PX then terminated the RSPV tachycardia. This is the first report of a persistent circumferential reentrant PV tachycardia with a 2:1 exit block simulating left atrial tachycardia (LAT). That the entire circuit was mapped by the circumferential catheter, with termination of tachycardia by a single application of RF energy at an area of fractionation within the circuit, provides good evidence that this was a reentrant tachycardia. PV reentry should be considered as one of the causes of AF or AT after a PV isolation procedure.