Differentiating Macroreentrant from Focal Atrial Tachycardias Occurred After Circumferential Pulmonary Vein Isolation

Abstract

Atrial tachycardias (ATs) are commonly observed following catheter ablation of atrial fibrillation (AF). The aim of this study was to identify ECG characteristics that differentiate focal from macroreentrant ATs after circumferential pulmonary vein isolation (CPVI). One hundred and twenty ATs that occurred after CPVI were mapped using a 3-dimensional mapping system in 87 patients with AF. Further ablation was performed to eliminate the ATs. The surface ECGs of 68 ATs in 41 consecutive patients (Group 1) were analyzed retrospectively to create diagnostic algorithms. The algorithms were tested in the second 46 consecutive patients (Group 2). Patients with macroreentrant AT had lower left atrial (LA) voltage than those with focal AT (1.3 ± 0.3 vs 1.5 ± 0.2 mV, P = 0.01). Focal AT had a higher incidence of a positive polarity in V6 compared with macroreentrant AT (88% vs 55%, P = 0.03). The positive amplitude of the flutter/P waves in V6 was higher for focal AT than macroreentrant AT. The cycle lengths of the focal ATs were longer than those for macroreentrant AT (296 ± 107 vs 244 ± 25 ms, P < 0.001). Right atrial macroreentrant AT had a higher incidence of a negative polarity in at least 1 precordial lead compared with LA macroreentry. The positive flutter waves in V1 could differentiate roof/mitral isthmus dependent from non-roof/mitral isthmus dependent macroreentry. This algorithm correctly differentiated the focal from macroreentrant ATs with a sensitivity of 94%, specificity of 91%, and predictive accuracy of 92% in Group 2. Different electrophysiological properties may facilitate the differentiation between macroreentrant and focal ATs after CPVI.