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Double loop reentrant atrial tachycardia following ablation for atrioventricular nodal reentrant tachycardia
Accepted Manuscript Double loop reentrant atrial tachycardia following ablation for atrioventricular nodal reentrant tachycardia
Ghassen Cheniti, Masateru Takigawa, Konstantinos Vlachos, Nathaniel Thompson, Κonstantinos P. Letsas, Arnaud Denis, Michel Haissaguerre, Nicolas Derval PII: DOI: Reference:
S0022-0736(18)30099-2 doi:10.1016/j.jelectrocard.2018.04.011 YJELC 52613
To appear in: Please cite this article as: Ghassen Cheniti, Masateru Takigawa, Konstantinos Vlachos, Nathaniel Thompson, Κonstantinos P. Letsas, Arnaud Denis, Michel Haissaguerre, Nicolas Derval , Double loop reentrant atrial tachycardia following ablation for atrioventricular nodal reentrant tachycardia. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yjelc(2017), doi:10.1016/j.jelectrocard.2018.04.011
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Double loop reentrant atrial tachycardia following ablation for atrioventricular nodal reentrant tachycardia Ghassen Cheniti, MD1, Masateru Takigawa, MD1, Konstantinos Vlachos, MD1, Nathaniel Thompson, MD1, Κonstantinos P. Letsas MD 2, Arnaud Denis, MD1, Michel Haissaguerre, MD1, Nicolas Derval, MD1
SC RI PT
. Hopital Cardiologique du Haut leveque, Service d'electrophysiologie-stimulation cardiaque, Bordeaux, France
NU
2.Department of Cardiology, Electrophysiology Laboratory, Evangelismos General Hospital of Athens, Athens, Greece
MA
Corresponding author: Dr Ghassen CHENITI
ED
Email: [email protected] Phone Number: +33786768042
CE
PT
Hôpital Cardiologique Haut Lévêque, 33600 Pessac, Bordeaux, France
AC
Conflict of interest: None declared
ACCEPTED MANUSCRIPT Abstract: We report a patient with a history of multiple ablations for recurrent atrioventricular nodal reentrant tachycardia who developed an atrial tachycardia four years after his last procedure. Subsequent electroanatomical
SC RI PT
mapping demonstrated double loop macro-reentrant atrial tachycardia consistent with a roof dependent flutter and a perimitral flutter. We successfully terminated the tachycardia by targeting isthmuses at sites of prior
AC
CE
PT
ED
MA
NU
ablation.
ACCEPTED MANUSCRIPT Introduction: A patient with a history of multiple ablations for recurrent atrioventricular nodal reentrant tachycardia (AVNRT) developed an atrial tachycardia four years after his last procedure. Subsequent electroanatomical
SC RI PT
mapping demonstrated double loop macro-reentrant atrial tachycardia consistent with a roof dependent flutter and a perimitral flutter. We successfully terminated the tachycardia by targeting isthmuses at sites of prior
NU
ablation. Case presentation:
MA
We report a case of a 65-year-old male with a history of drug refractory
ED
AVNRT requiring multiple ablations. In 1988, we first performed a fast pathway modification that caused PR prolongation. At a subsequent ablation we
PT
mapped and confirmed two distinct atypical AVNRT circuits (Figure 1). We
CE
located the site of earliest retrograde atrial activation at the posterior and mid
AC
left inter-atrial septum, indicating a left-sided insertion of the retrograde pathway (1). We applied a total of 22 minutes of radiofrequency using retroaortic and transeptal approaches. As the patient had multiple symptomatic recurrences, we proceeded with a SP modification. Unfortunately, this led to complete atrioventricular block and required dual chamber pacemaker implantation.
ACCEPTED MANUSCRIPT The patient presented four years later with an atrial tachycardia. We mapped the tachycardia with a high density mapping system (Rhythmia, Boston
Scientific).
The
activation
map
demonstrated
double
loop
macroreentrant atrial tachycardia (AT1): both a roof dependent atrial
SC RI PT
tachycardia and an atypical mitral isthmus dependent AT (figure-2, video-1). Entrainment mapping confirmed the presence of double loop reentrant AT. Anterior, anteroseptal, posterior part of the LA and lateral mitral annulus were
NU
actively involved in the circuit showing a post pacing interval - tachycardia cycle length (PPI-TCL) <20 msec. We identified two critical isthmuses at the site of
MA
previous ablation. The first isthmus was located at the antero-septal part of the
ED
left atrium. The second was located at the postero-septal part of the left atrium, between the mitral valve and a septal line of block. After ablating the
PT
first isthmus we converted double loop macrorrentant AT1 to a second AT
CE
(AT2) with longer CL but with similar proximal to distal CS activation sequence.
AC
This transition was associated with the P wave morphology in the inferior leads becoming biphasic (supplemental-1). Activation mapping of the AT2 confirmed the persistence of a mitral isthmus dependent AT (figure-3; Video-2). Targeting the second isthmus terminated AT2 to sinus rhythm.
ACCEPTED MANUSCRIPT Discussion: We report the case of a scar-related left atrial tachycardia in the setting of prior left-sided ablation for AVNRT. Although more commonly thought a sequelae of AF ablation or surgical repair (2), this case highlights the potential
SC RI PT
creation of substrate necessary for reentry and AT maintenance with any physical modification of the atria. We identified two critical isthmuses of the tachycardia circuit and successfully ablated and terminated the arrhythmia.
NU
The identification of the relatively narrow isthmuses of the tachycardia meant that we were not required to create longer lines of block on the atrial roof and
MA
mitral isthmus. The high-resolution and high spatial sampling of the Rhythmia
ED
mapping system allowed for accurate identification of the critical isthmuses required for AT maintenance (3). In the future this may allow for shorter lines
AC
Conclusion:
CE
PT
of ablation to transect and eliminate AT circuits.
We report a rare complication of ablation for AVNRT consisting in a double loop macroreentrant atrial tachycardia. We successfully mapped and targeted the critical isthmuses at the site of previous ablation, rather than performing anatomical lines.
ACCEPTED MANUSCRIPT References: 1.
Katritsis DG, Ellenbogen KA, Becker AE. Atrial activation during atrioventricular nodal
reentrant tachycardia: studies on retrograde fast pathway conduction. Heart Rhythm. 2006;3(9):993-1000. Daubert JP. Iatrogenic left atrial tachycardias: where are we? J Am Coll Cardiol.
SC RI PT
2.
2007;50(18):1788-90. 3.
Takigawa M, Derval N, Frontera A, Martin R, Yamashita S, Cheniti G, et al. Revisiting
anatomic macroreentrant tachycardia after atrial fibrillation ablation using ultrahigh-
NU
resolution mapping: Implications for ablation. Heart Rhythm. 2017.
MA
Figures:
Figure 1: A: 12 lead ECG in sinus rhythm showing a prolonged baseline PR interval (328ms).
ED
Notice the bifid P wave morphology in inferior leads, It’s due to extensive septal ablation
PT
and highlights the importance of septal interatrial conduction in addition to interatrial bridges. B and C: Atypical AVNRTs with different retrograde P wave morphology suggesting
CE
different retrograde exit sites.
AC
Figure 2: Activation map of AT 1. Three views are displayed including antero-posterior (A), LAO (B) and posterior (C) views. The map shows a double loop macroreentry associating a roof dependent atrial tachycardia and a perimitral atrial tachycardia. We identified fragmented potentials of low-amplitude(0.09mV) and long duration(120ms) at the anteroseptum and anterior LA (shown by a star). Ablation in this region of slow conduction converted AT1 to AT2. A second area slow conduction was present in inferior septum, close to the mitral annulus, where collision of two wavefronts occurred (perpendicular lines), this area represented the critical isthmus of AT2. IRPV: intermediate right pulmonary vein, LAA: left atrial
ACCEPTED MANUSCRIPT appendage, LIPV: left inferior pulmonary vein, LSPV: left superior pulmonary vein, MA: mitral annulus, RIPV: right inferior pulmonary vein, RSPV: right superior pulmonary vein
Figure 3: Activation map of AT 2. Three views are displayed including antero-posterior (A), LAO (B) and posterior (C) views. The map shows a perimitral flutter with an area of slow conduction located at the inferior septum, between the mitral annulus and septal line of
SC RI PT
block. IRPV: intermediate right pulmonary vein, LAA: left atrial appendage, LIPV: left inferior pulmonary vein, LSPV: left superior pulmonary vein, MA: mitral annulus, RIPV: right inferior pulmonary vein, RSPV: right
AC
CE
PT
ED
MA
NU
superior pulmonary vein.
ACCEPTED MANUSCRIPT Figure 1
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Ghassen Cheniti, Masateru Takigawa, Konstantinos Vlachos, Nathaniel Thompson, Κonstantinos P. Letsas, Arnaud Denis, Michel Haissaguerre, Nicolas Derval PII: DOI: Reference:
S0022-0736(18)30099-2 doi:10.1016/j.jelectrocard.2018.04.011 YJELC 52613
To appear in: Please cite this article as: Ghassen Cheniti, Masateru Takigawa, Konstantinos Vlachos, Nathaniel Thompson, Κonstantinos P. Letsas, Arnaud Denis, Michel Haissaguerre, Nicolas Derval , Double loop reentrant atrial tachycardia following ablation for atrioventricular nodal reentrant tachycardia. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yjelc(2017), doi:10.1016/j.jelectrocard.2018.04.011
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Double loop reentrant atrial tachycardia following ablation for atrioventricular nodal reentrant tachycardia Ghassen Cheniti, MD1, Masateru Takigawa, MD1, Konstantinos Vlachos, MD1, Nathaniel Thompson, MD1, Κonstantinos P. Letsas MD 2, Arnaud Denis, MD1, Michel Haissaguerre, MD1, Nicolas Derval, MD1
SC RI PT
. Hopital Cardiologique du Haut leveque, Service d'electrophysiologie-stimulation cardiaque, Bordeaux, France
NU
2.Department of Cardiology, Electrophysiology Laboratory, Evangelismos General Hospital of Athens, Athens, Greece
MA
Corresponding author: Dr Ghassen CHENITI
ED
Email: [email protected] Phone Number: +33786768042
CE
PT
Hôpital Cardiologique Haut Lévêque, 33600 Pessac, Bordeaux, France
AC
Conflict of interest: None declared
ACCEPTED MANUSCRIPT Abstract: We report a patient with a history of multiple ablations for recurrent atrioventricular nodal reentrant tachycardia who developed an atrial tachycardia four years after his last procedure. Subsequent electroanatomical
SC RI PT
mapping demonstrated double loop macro-reentrant atrial tachycardia consistent with a roof dependent flutter and a perimitral flutter. We successfully terminated the tachycardia by targeting isthmuses at sites of prior
AC
CE
PT
ED
MA
NU
ablation.
ACCEPTED MANUSCRIPT Introduction: A patient with a history of multiple ablations for recurrent atrioventricular nodal reentrant tachycardia (AVNRT) developed an atrial tachycardia four years after his last procedure. Subsequent electroanatomical
SC RI PT
mapping demonstrated double loop macro-reentrant atrial tachycardia consistent with a roof dependent flutter and a perimitral flutter. We successfully terminated the tachycardia by targeting isthmuses at sites of prior
NU
ablation. Case presentation:
MA
We report a case of a 65-year-old male with a history of drug refractory
ED
AVNRT requiring multiple ablations. In 1988, we first performed a fast pathway modification that caused PR prolongation. At a subsequent ablation we
PT
mapped and confirmed two distinct atypical AVNRT circuits (Figure 1). We
CE
located the site of earliest retrograde atrial activation at the posterior and mid
AC
left inter-atrial septum, indicating a left-sided insertion of the retrograde pathway (1). We applied a total of 22 minutes of radiofrequency using retroaortic and transeptal approaches. As the patient had multiple symptomatic recurrences, we proceeded with a SP modification. Unfortunately, this led to complete atrioventricular block and required dual chamber pacemaker implantation.
ACCEPTED MANUSCRIPT The patient presented four years later with an atrial tachycardia. We mapped the tachycardia with a high density mapping system (Rhythmia, Boston
Scientific).
The
activation
map
demonstrated
double
loop
macroreentrant atrial tachycardia (AT1): both a roof dependent atrial
SC RI PT
tachycardia and an atypical mitral isthmus dependent AT (figure-2, video-1). Entrainment mapping confirmed the presence of double loop reentrant AT. Anterior, anteroseptal, posterior part of the LA and lateral mitral annulus were
NU
actively involved in the circuit showing a post pacing interval - tachycardia cycle length (PPI-TCL) <20 msec. We identified two critical isthmuses at the site of
MA
previous ablation. The first isthmus was located at the antero-septal part of the
ED
left atrium. The second was located at the postero-septal part of the left atrium, between the mitral valve and a septal line of block. After ablating the
PT
first isthmus we converted double loop macrorrentant AT1 to a second AT
CE
(AT2) with longer CL but with similar proximal to distal CS activation sequence.
AC
This transition was associated with the P wave morphology in the inferior leads becoming biphasic (supplemental-1). Activation mapping of the AT2 confirmed the persistence of a mitral isthmus dependent AT (figure-3; Video-2). Targeting the second isthmus terminated AT2 to sinus rhythm.
ACCEPTED MANUSCRIPT Discussion: We report the case of a scar-related left atrial tachycardia in the setting of prior left-sided ablation for AVNRT. Although more commonly thought a sequelae of AF ablation or surgical repair (2), this case highlights the potential
SC RI PT
creation of substrate necessary for reentry and AT maintenance with any physical modification of the atria. We identified two critical isthmuses of the tachycardia circuit and successfully ablated and terminated the arrhythmia.
NU
The identification of the relatively narrow isthmuses of the tachycardia meant that we were not required to create longer lines of block on the atrial roof and
MA
mitral isthmus. The high-resolution and high spatial sampling of the Rhythmia
ED
mapping system allowed for accurate identification of the critical isthmuses required for AT maintenance (3). In the future this may allow for shorter lines
AC
Conclusion:
CE
PT
of ablation to transect and eliminate AT circuits.
We report a rare complication of ablation for AVNRT consisting in a double loop macroreentrant atrial tachycardia. We successfully mapped and targeted the critical isthmuses at the site of previous ablation, rather than performing anatomical lines.
ACCEPTED MANUSCRIPT References: 1.
Katritsis DG, Ellenbogen KA, Becker AE. Atrial activation during atrioventricular nodal
reentrant tachycardia: studies on retrograde fast pathway conduction. Heart Rhythm. 2006;3(9):993-1000. Daubert JP. Iatrogenic left atrial tachycardias: where are we? J Am Coll Cardiol.
SC RI PT
2.
2007;50(18):1788-90. 3.
Takigawa M, Derval N, Frontera A, Martin R, Yamashita S, Cheniti G, et al. Revisiting
anatomic macroreentrant tachycardia after atrial fibrillation ablation using ultrahigh-
NU
resolution mapping: Implications for ablation. Heart Rhythm. 2017.
MA
Figures:
Figure 1: A: 12 lead ECG in sinus rhythm showing a prolonged baseline PR interval (328ms).
ED
Notice the bifid P wave morphology in inferior leads, It’s due to extensive septal ablation
PT
and highlights the importance of septal interatrial conduction in addition to interatrial bridges. B and C: Atypical AVNRTs with different retrograde P wave morphology suggesting
CE
different retrograde exit sites.
AC
Figure 2: Activation map of AT 1. Three views are displayed including antero-posterior (A), LAO (B) and posterior (C) views. The map shows a double loop macroreentry associating a roof dependent atrial tachycardia and a perimitral atrial tachycardia. We identified fragmented potentials of low-amplitude(0.09mV) and long duration(120ms) at the anteroseptum and anterior LA (shown by a star). Ablation in this region of slow conduction converted AT1 to AT2. A second area slow conduction was present in inferior septum, close to the mitral annulus, where collision of two wavefronts occurred (perpendicular lines), this area represented the critical isthmus of AT2. IRPV: intermediate right pulmonary vein, LAA: left atrial
ACCEPTED MANUSCRIPT appendage, LIPV: left inferior pulmonary vein, LSPV: left superior pulmonary vein, MA: mitral annulus, RIPV: right inferior pulmonary vein, RSPV: right superior pulmonary vein
Figure 3: Activation map of AT 2. Three views are displayed including antero-posterior (A), LAO (B) and posterior (C) views. The map shows a perimitral flutter with an area of slow conduction located at the inferior septum, between the mitral annulus and septal line of
SC RI PT
block. IRPV: intermediate right pulmonary vein, LAA: left atrial appendage, LIPV: left inferior pulmonary vein, LSPV: left superior pulmonary vein, MA: mitral annulus, RIPV: right inferior pulmonary vein, RSPV: right
AC
CE
PT
ED
MA
NU
superior pulmonary vein.
ACCEPTED MANUSCRIPT Figure 1
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ACCEPTED MANUSCRIPT Figure 2
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