Catheter Ablation of Atypical Atrial Flutter after Cardiac Surgery Using a 3-D Mapping System

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1 Catheter Ablation of Atypical Atrial Flutter after Cardiac Surgery Using a 3-D Mapping System Myung-Jin Cha Seil Oh ECG & EP CASES Myung-Jin Cha, MD, Seil Oh, MD, PhD, FHRS Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea Catheter ablation of atypical atrial flutter after cardiac surgery using a 3-D mapping system ABSTRACT Three-dimensional (3D) mapping systems are useful tools for the diagnosis and treatment of atypical arrhythmias following open heart surgery. In this case, a patient experienced incessant tachycardia after aortic valve surgery. Two-dimensional fluoroscopy-guided catheter ablation and intensive antiarrhythmic pharmacological treatment, in addition to a permanent pacemaker, failed to control the tachycardia. A 3D mapping system revealed that the mechanism of the tachycardia involved macroreentry around the right atriotomy scar, and the tachycardia circuit was blocked by 3D-guided catheter ablation. Key words: arrhythmias catheter ablation 3D mapping systems Received: March 26, 2013 Accepted: March 30, 2013 Correspondence: Seil Oh, MD, PhD, FHRS, Professor of Internal Medicine Seoul National University College of Medicine and Seoul National University Hospital 101 Daehak-ro, Jongno-gu, Seoul , Korea Tel: , Fax: , seil@snu.ac.kr VOL.14 NO.1 33

2 ECG & EP CASES Figure 1. Tachycardia electrocardiogram. Flutter wave morphology does not show a saw-tooth appearance as in typical atrial flutter. 34 The Official Journal of Korean Heart Rhythm Society

3 ECG & EP CASES Figure 2. Entrainment mapping. Stimulation was delivered at the septal side using an ablation catheter (ABLd, white arrow in the fluoroscopy image). Postpacing interval is 310 ms, which indicates that the septal wall is a remote site from the reentry circuit. wall rather than the cavotricuspid isthmusdependent reentry, and we performed electroanatomical mapping using the CARTO 3 system (Biosene Webster, Diamond Bar, Co USA). The activation map revealed that the tachycardia circuit was the right atriotomy scar-related reentry (Figure. 3). Ablation was performed at gaps in the scar area and at the isthmus between the scar and the tricuspid annulus using a Thermocool SF irrigated catheter (Biosene Webster, Diamond Bar, CA, USA) and RF energy with W. Tachycardia was terminated during ablation, and bidirectional block was confirmed after ablation. Conclusion Intra-atrial reentrant tachycardia related to Figure 3. Electroanatomical mapping. Activation map shows macroreentry at the right atrial free wall. Red dots indicate ablation sites on gaps in the scar area and the isthmus between the scar and the tricuspid annulus. Tachycardia was terminated during RF energy delivery at the area marked by the yellow dot. VOL.14 NO.1 35

4 ECG & EP CASES Reference 1. Jackman WM, Wang XZ, Friday KJ, Roman CA, Moulton KP, Beckman KJ, McClelland JH, Twidale N, Hazlitt HA, Prior MI. Catheter ablation of accessory atrioventricular pathways (wolffparkinson-white syndrome) by radiofrequency current. N Engl J Med. 1991;324: Calkins H, Sousa J, el-atassi R, Rosenheck S, de Buitleir M, Kou WH, Kadish AH, Langberg JJ, Morady F. Diagnosis and cure of the wolff-parkinson-white syndrome or paroxysmal supraventricular tachycardias during a single electrophysiologic test. N Engl J Med. 1991;324: Ben-Haim SA, Osadchy D, Schuster I, Gepstein L, Hayam G, Josephson ME. Nonfluoroscopic, in vivo navigation and mapping technology. Nat Med.1996;2: Schumacher B, Jung W, Lewalter T, Wolpert C, Luderitz B. Verification of linear lesions using a noncontact multielectrode array catheter versus conventional contact mapping techniques. J Cardiovasc Electrophysiol.1999;10: de Groot NM, Bootsma M, van der Velde ET, Schalij MJ. Threedimensional catheter positioning during radiofrequency ablation in patients: First application of a real-time position management system. J Cardiovasc Electrophysiol. 2000;11: Wittkampf FH, Wever EF, Derksen R, Wilde AA, Ramanna H, Hauer RN, Robles de Medina EO. Localisa: New technique for real-time 3-dimensional localization of regular intracardiac electrodes. Circulation. 1999;99: Triedman JK, Saul JP, Weindling SN, Walsh EP. Radiofrequency ablation of intra-atrial reentrant tachycardia after surgical palliation of congenital heart disease. Circulation. 1995;91: Van Hare GF, Lesh MD, Ross BA, Perry JC, Dorostkar PC. Mapping and radiofrequency ablation of intraatrial reentrant tachycardia after the Senning or Mustard procedure for transposition of the great arteries. Am J Cardiol. 1996;77: The Official Journal of Korean Heart Rhythm Society

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