Symptomatic Atrial Tachycardia Research Articles

Clinical and electrophysiological characteristics and long term outcomes of catheter ablation for right and left atrial tachycardias

Abstract Background Atrial tachycardias (AT) are complex supraventricular tachycardias which are refractory to antiarrhythmic drugs that require catheter ablation. Purpose In this trial, we aimed to evaulate the outcomes of catheter ablation in patients with symptomatic atrial tachycardia, define the acute procedural success and the recurrence rates in long-term follow-up and determine the clinical and electrophysiological features that affect these outcomes. Methods A total of 666 [mean age: 55 ±16, gender: 344 (51.7%) female] symptomatic patients with AT were enrolled. Prior catheter or surgical ablation history for ATa was present in 199 (29.9%) and 18 (2.7%) of these patients, respectively. Activation mapping was performed during tachycardia in all patients as well as entrainment mapping when needed. Voltage mapping were performed in sinus rhythm in both atriums, late potential mapping was also performed in some patients. Low voltage areas and signals with continuous-fragmented morphology were tagged. Results Macroreentry was the primary mechanism in right and left atrium (70.2% and 52.8%, respectively). Cavotricuspid isthmus (CTI) dependent macroreentry was the most frequent mechanism in right ATs and perimitral reentry and roof-dependent macroreentry were the most common mechanisms in left ATs. A total of 59 (7.5%) complications were observed in 780 procedures.(2.1% major and 5.5% minor) Acute procedural success was 95.9%. Freedom from ATa was 72.8 % during a mean follow-up of 39±23 months. Freedom from ATa after index procedure was 82.3% at 12 months and 75.9 % at 24 months. After multiple procedures, freedom from ATa was 90% at 12 months and 86% at 24 months during the follow-up. In multivariate Cox regression analysis, atrial fibrillation (AF) [(HR) 2.43, 95% c(CI) 1.78-3.30; p<0.001] , history of cardiac surgery [(HR) 1.68, 95% c(CI) 1.22-2.30; p=0.001] and moderate to severe tricuspid regurgitation [(HR) 1.47, 95% c(CI) 1.08-2.01; p=0.014] were significant predictors of ATa recurrence. Conclusion Our findings demonstrated that tailored catheter ablation of ATs especially guided by high density mapping has a high acute success rate and favourable long-term outcomes in patients with symptomatic AT episodes.

PO-01-110 ATRIAL TORSADES DE POINTES POST COVID MYOCARDITIS

Among patients with COVID-19 infection, the risk of adverse cardiovascular outcome, particularly myocarditis and dysrhythmias remain elevated at least up to one year after infection. We present a case of atrial tachycardia and atrial Torsades de Pointes from COVID myocarditis, persisted 6 months after infection, which was successfully managed by ablation. A 25-year-old female presented with mild COVID-19 infection, Omicron variant, in May 2022. One month after, her Covid infection resolved; she presented with symptomatic atrial tachycardia, paroxysmal atrial fibrillation and flutter. ECG showed multiple blocked premature atrial contractions (PAC) (Figure 1A). Holter monitor showed PAC triggered atrial tachycardia degenerating to paroxysmal atrial fibrillation, atrial Torsades de Pointes. She has mild persistent troponin elevation. Echocardiography was normal. Cardiac MRI showed evidence of mild myocarditis with subepicardial late Gadolinium enhancement (LEG) along the lateral mid-apical left ventricular wall and edema. (Figure 1B). She was treated with Colchicine for 2 months. Repeat cardiac MRI 4 months after COVID infection showed resolution of edema and LGE. However, her symptomatic PAC and atrial tachycardia did not respond to betablocker and amiodarone. She underwent electrophysiology study. Activation mapping of PAC using CARTO revealed earliest activation at the right anterior atrial wall, with close proximity to tricuspid valve; unipolar signal showed QS pattern, bipolar signal showed 16 msec pre-PAC (Figure 1C and 1D). Mechanical pressure from ThermoCool SmartTouch ablation catheter (Biosense Webster Inc.) at this site suppressed the PAC. Radiofrequency ablation resulted with an initial acceleration and then disappearance of the PAC. We did not isolate pulmonary veins or ablate cavotricuspid isthmus. Post ablation, PAC and atrial fibrillation were not inducible on Isoproterenol. N/A Covid myocarditis can result in dysrhythmia that lingers long after Covid myocarditis has resolved. Covid myocarditis can be caused by direct viral invasion of myocytes or more commonly is inflammatory related to cytokine release and edema. Our case demonstrates that dysrhythmias can persist despite resolution of myocarditis. Catheter ablation can successfully to treat these arrhythmias. This case highlights the importance of recognizing cardiac dysrhythmia as possible the long-term cardiac complications of COVID-19, requiring specific treatment such as catheter ablation.

Macroreentrant scar-mediated atrial tachycardia terminated by a nonpropagated stimulus within a narrow diastolic isthmus: Electroanatomic correlation

A 76-year-old woman with coronary artery disease status post coronary artery bypass grafting and paroxysmal atrial fibrillation and flutter status post cavotricuspid isthmus ablation underwent radiofrequency (RF) ablation of recurrent, symptomatic atrial tachycardia (AT) (cycle length [CL] 378 ms). High-density activation mapping using a Biosense Webster (Diamond Bar, CA) PentaRay® catheter revealed a macroreentrant circuit rotating clockwise (right anterior oblique, caudal view) along the right atrial free wall and conducting slowly through a narrow isthmus (zigzag line) (Figure 1A).

Correction to: Gagyi et al, New Possibilities in the Treatment of Brief Episodes of Highly Symptomatic Atrial Tachycardia: The Usefulness of Single-Position Single-Beat Charge Density Mapping.

Correction to: Gagyi et al, New Possibilities in the Treatment of Brief Episodes of Highly Symptomatic Atrial Tachycardia: The Usefulness of Single-Position Single-Beat Charge Density Mapping.

Catheter ablation of macroreentrant atrial tachycardias following transconduit puncture access in a patient after total cavopulmonary connection with an extracardiac conduit

We present the case of a 23-year-old male diagnosed with a complex congenital heart disease (with single ventricle physiology) which necessitated many surgical interventions including total cavopulmonary connection. The patient presents with recurrent (almost daily) highly symptomatic atrial tachycardia with rapid ventricular rate and poor haemodynamic tolerance. Due to failure of antiarrhythmic drug therapy the patient was referred for catheter ablation. Atrial access was provided following transconduit puncture with a standard transseptal set. Crossing to the atrium with the transseptal introducer was not successful due to resistance from the conduit and the atrial wall. Therefore, balloon dilation of the puncture using a cutting balloon was carried out which resulted in easy crossing to the atrium with a steerable transseptal introducer. Several atrial tachyarrhythmias were induced two of which allowed mapping demonstrating a macroreentrant tachycardia dependent on the cavoannular isthmus as well as a complex figure-of-eight circuit involving right pulmonary veins and the right atrial appendage. Linear lesions transecting the critical isthmuses of the two circuits were delivered which rendered the patient noninducible. During a 9-month follow-up period the patient remained arrhythmia free.

Treatment of symptomatic atrial tachycardia in complex anatomic conditions: use and outcome of ablation in patients after damus-kaye-stansel surgery

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial tachycardias (AT) are amongst the most frequent complications in adult patients with congenital heart disease (ACHD). Their incidence mainly depends on age and complexity of underlying defect. AT has a marked impact on morbidity and mortality and is associated with sudden cardiac death particularly in complex ACHD patients. The arrhythmic substrate can be variable from re-entry to multifocal resulting in demanding requirements for electrophysiologic ablation procedures (EP) and thus, relatively high rates of recurrence. Methods and results Retrospective analysis of ACHD patients with prior Damus-Kaye-Stansel (DKS) surgery treated at one of the largest specialized tertiary centers for ACHD patients worldwide. Analysis focussed on occurrence of AT, respective treatment and outcome of EP. Over a median observation time of 15 years, 13 patients with prior DKS surgery and complex congenital heart defects of different types but uniformly Fontan circulation, were identified (median age 22.0 years (IQR 20.5 – 25.5), 76.9% male, 92.3% NYHA Class I, median systemic ventricular ejection fraction 58.5%, 69.2% extracardiac tunnel). Seven patients (53.8%) presented with symptomatic AT (median cyclic length 440 ms (IQR 360.0 – 517.5)). Of these, six patients underwent EP. Median procedure time was 180.5 min (IQR 160.8 – 274.5), median fluoroscopy time 1.56 min (IQR 0.51 – 4.73) and radiofrequency time 851 sec (265.0 -2005.0). Remote magnetic navigation was used to access ablation site through a retrograde access via the aortic as well as the neo-aortic valve. Three-dimensional image integration aided in mapping and ablation. Throughout the procedure as well as in follow-up visits, no reportable complications were observed. After a mean of 1.5 procedures, all analysed patients stayed complaint-free throughout a median time-interval of 13 months. Conclusion AT are frequent in complex univentricular situations after Damus-Kaye-Stansel surgery (53.8%). Although more than one procedure (mean 1.5) was necessary to achieve satisfactory results even in experienced hands, EP appears to be an appropriate treatment strategy in this young and otherwise healthy patient cohort. According to our analysis, EP is feasible and safe in centers with knowledge of specific anatomic characteristics of congenital heart disease and when the appropriate technical infrastructure is present. Access to ablation site was performed by remote magnetic navigation in the majority of procedures. The floppy catheter was navigated through the neo-aortic as well as through the aortic valve without observable peri- or postinterventional complications. Mapping with three-dimensional image integration facilitated EP and led to a relatively low radiation exposure with the known benefits for the patient as well as for the healthcare professionals involved in the procedure. Abstract Figure.

Multiple peritricuspidal reentry tachycardias after cardiac infiltration by leukaemia: a case report.

BackgroundCardiac involvement by malignant lymphocytic neoplasms is a rare phenomenon. Little is known concerning cardiotoxicity in the chronic phase after completion of treatment.Case summaryA 50-year-old woman with a past history of cardiac involvement of acute lymphoblastic leukaemia (ALL) underwent electrophysiologic study and catheter ablation for symptomatic atrial tachycardia (AT). She was diagnosed with ALL when she was 8 years old and treated with systematic chemotherapy with prednisolone and vincristine. After complete remission, she suffered from repeated palpitations beginning at the age of 16 years. Electrophysiologic study using high-density (HD) mapping showed two types of peritricuspid AT in addition to low voltage in the right atrium with conduction delay.DiscussionCardiac involvement by malignant lymphocytic neoplasms is a rare phenomenon, and cardiac infiltration often disappears after remission of ALL. Thus, little is known about cardiac electrophysiological characteristics in the chronic phase of complete remission of ALL. We describe a rare case of a patient with multiple peritricuspidal reentry tachycardias after cardiac infiltration by leukaemia using a HD mapping system.

Systemic-to-pulmonary arterial connections simulating pulmonary emboli in a patient with Tetralogy of Fallot

A middle-aged patient with a history of Tetralogy of Fallot repair (status post modified Blalock-Taussig shunt, right ventricular outlet tract reconstruction and ventricular septal defect repair, with more recent pulmonary...

Electroanatomic mapping and catheter ablation of atrial tachycardia originating from the tricuspid annulus

We read with great interest with a recent case report from Cay et al. [1] published in International Journal of Cardiology. They reported an interesting case of successful radiofrequency ablation of idiopathic ventricular arrhythmia originating from the anterolateral free wall of tricuspid annulus (TA). We recently encountered a patient presenting with atrial tachycardia (AT) originating from the anterolateral free wall of the tricuspid annulus, who was successfully ablated using 3dimensional electroanatomic mapping system. A 62-year-old male patient was referred to our department for catheter ablation for symptomatic atrial tachycardia, which was resistant to metoprolol, propafenone, and amiodarone. He had a history of hypertension for 10 years. No underlying structural heart disease was detected by echocardiogram. P-wave morphology during tachycardia (Fig. 1) was “W” shape in the inferior leads, iso in lead I, and predominantly negative in lead V1, all suggesting the AT originating from the lateral free wall of the tricuspid annulus. During electrophysiologic study guided by the noncontact Ensite Array (EA) mapping system (St. Jude Medical, St. Paul, MN, USA), the tachycardia could be induced by atrial burst pacing. The cycle length of the tachycardia was 560 ms. The earliest atrial activation site during the arrhythmia was found near the anterolateral free wall of the TA (Movie). Activation mapping also showed the AT origin and its propagation to the other sites of the right atrium. Radiofrequency ablation using irrigated ablation catheter (Cool Path Ablation Catheter, St. Jude Medical) with average power of 30 W and maximum temperature of 43 °C at this site (Fig. 2) successfully terminated the tachycardia (Fig. 3), and AT was no longer inducible with and without isoproterenol infusion. The patient remained free from any atrial arrhythmias without anti-arrhythmic drugs during a follow-up period of one year. The focal atrial tachycardia originating from the TA is not commonly seen, and has been reported in separate cases [2–4] and case series [5,6] with an incidence of 9–10% of right atrial tachycardia. Furthermore, AT arising from the anterolateral free wall of the TA is relatively rare. Conventionally, intracardiac mapping of focal AT using 1 or 2 roving catheters was utilized to find the origin of AT. Noncontact mapping systems provide an accurate guidance for mapping and ablation of focal AT [7,8]. Supplementary data to this article can be found online at http:// dx.doi.org/10.1016/j.ijcard.2013.06.084. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

Successful ablation of two right atrial tachycardias on either side of the lateral tunnel patch in a patient with double inlet left ventricle and total cavopulmonary connection: Two sites and two mechanisms

[first paragraph of article] Surgical strategy for patients born with a physiological univentricular heart has evolved from atrio-pulmonary (AP) Fontan (right atrium (RA) to pulmonary artery) to its modification, total cavopulmonary connection (TCPC),2 with the goal of reduced post-operative incidence of supraventricular tachycardia (SVT). However, TCPC patients may also present with symptomatic atrial tachycardia, and the sites of origin can be difficult to access due to the surgical strategy. Owing to recent technological advances in the field of electrophysiology, such as electroanatomic mapping (EAM) irrigated-tip catheters9 and remote magnetic navigation (RMN) catheter ablation has become a more relevant and important therapeutic modality for congenital heart disease associated-SVTs. We report on a 33-year-old male, with double inlet left ventricle (DILV) status post TCPC, who underwent catheter ablation of two different atrial tachycardias originating in different parts of the divided RA.

Catheter Ablation of Atrial Fibrillation Originating from Superior Vena Cava

Atrial fibrillation originating from rapid firing foci in the superior vena cava is rare. Its electrophysiological features and catheter ablation techniques are described in this report. A decapolar catheter was positioned in the superior vena cava to map the origin of the atrial fibrillation in a 39-year-old female patient who had a 3-year history of symptomatic atrial tachycardia and fibrillation. Intracardiac mapping showed rapid firing foci in the anterior wall of the superior vena cava (SVC), 2.0 cm above the SVC-right atrium junction. During tachycardia, the focal electrogram from SVC was 55 msec earlier than the P waves on body surface ECG. Radiofrequency catheter ablation successfully abolished SVC potentials, resulting in a SVC-atrium conduction block. There was no recurrence of atrial arrhythmia after a 14-month follow-up. Rapid activities from the muscle sleeves in the SVC may cause atrial fibrillation. Such a focal atrial fibrillation can be eliminated by isolating the arrhythmogenic SVC with radiofrequency catheter ablation.

Fontan-type procedures: residual lesions and late interventions

Background. The purpose of this study was to determine the type and incidence of hemodynamic and electrophysiological abnormalities requiring surgical or catheter-based interventions in a single-center long-term experience. Methods. Eighty-eight patients with a follow-up of at least 5 years (mean follow-up, 9.6 ± 2.6 years) after Fontan-type procedures were included. All patients had undergone cardiac catheterization either as part of the regular postoperative protocol or because of symptomatic atrial tachycardia or increasing cyanosis. Results. Freedom from reoperation for up to 5 years was documented for 82% of patients and decreased to 76% after 8 years. Late reoperations included conversion of an atriopulmonary anastomosis to a total cavopulmonary anastomosis in 2 patients with atrial dysrhythmia and implantation of an extracardiac conduit in 1 patient with left atrial isomerism and intrapulmonary arteriovenous malformations after a Kawashima operation. Decline in sinus node function with symptomatic bradycardia required pacemaker therapy in 10 patients (11%). Transcatheter interventions included fenestration occlusion in 5 of the 11 patients with initial baffle fenestration. In 6 of 17 patients with aortopulmonary collaterals, coil occlusion was indicated to reduce future systemic ventricular volume load. Various systemic venous collaterals were documented in 11 patients and required coil occlusion in 2. One patient with symptomatic protein-losing enteropathy underwent transcatheter fenestration creation without sustained relief of symptoms. Freedom from transcatheter interventions decreased from 94% to 82% after 5 and 10 years, respectively. Conclusions. During long-term follow-up, reoperations are rare and mainly involve Fontan conversion to either a lateral-tunnel or extracardiac-conduit procedure. Detailed angiographic evaluation on a routine basis allows identification of the vascular sites of origin of aortopulmonary collateral vessels and systemic venous collaterals potentially developing during long-term follow-up. Transcatheter interventions including fenestration occlusion and occlusion of venous collaterals and aortopulmonary collaterals were performed to maintain and improve the Fontan circulation in clinically symptomatic and asymptomatic patients. During long-term follow-up after Fontan-type operations, a regular postoperative cardiac catheterization protocol is recommended.

Incidence and clinical significance of inducible atrial tachycardia in patients with atrioventricular nodal reentrant tachycardia.

The purpose of this prospective study was to determine the prevalence and clinical significance of inducible atrial tachycardia in patients undergoing slow pathway ablation for AV nodal reentrant tachycardia who did not have clinically documented episodes of atrial tachycardia. Twenty-seven (15%) of 176 consecutive patients who underwent slow pathway ablation for AV nodal reentrant tachycardia were found to have inducible atrial tachycardia with a mean cycle length of 351+/-95 msec. The atrial tachycardia was sustained in 7 (26%) of 27 patients and was isoproterenol dependent in 20 patients (74%). The atrial tachycardia was not ablated or treated with medications, and the patients were followed for 9.7+/-5.8 months. Six (22%) of the 27 patients experienced recurrent palpitations during follow-up. In one patient each, the palpitations were found to be due to sustained atrial tachycardia, nonsustained atrial tachycardia, recurrence of AV nodal reentrant tachycardia, paroxysmal atrial fibrillation, sinus tachycardia, and frequent atrial premature depolarizations. Thus, only 2 (7%) of 27 patients with inducible atrial tachycardia later developed symptoms attributable to atrial tachycardia. Atrial tachycardia may be induced by atrial pacing in 15% of patients with AV nodal reentrant tachycardia. Because the vast majority of patients do not experience symptomatic atrial tachycardia during follow-up, treatment for atrial tachycardia should be deferred and limited to the occasional patient who later develops symptomatic atrial tachycardia.