Korean Circ J.  2013 Jan;43(1):29-37. 10.4070/kcj.2013.43.1.29.

Characteristics and Outcomes of Atrial Tachycardia Originating from the Sinus Venosus during Catheter Ablation of Atrial Fibrillation

• Park YM
• Kook H
• Kim W
• Lee SK
• Choi JI
• Lim HE
• Park SW
• Kim YH

• KMID: 1722998
• DOI: http://doi.org/10.4070/kcj.2013.43.1.29

Abstract

BACKGROUND AND OBJECTIVES
The sinus venosus (SV) is not a well known source of atrial tachycardia (AT), but it can harbor AT during catheter ablation of atrial fibrillation (AF).
SUBJECTS AND METHODS
A total of 1223 patients who underwent catheter ablation for AF were reviewed. Electrophysiological and electrocardiographic characteristics and outcomes after catheter ablation of AT originating from the SV were investigated.
RESULTS
Ten patients (0.82%) demonstrated AT from the SV (7 males, 53.9+/-16.0 years, 6 persistent) during ablation of AF. The mean cycle length was 281+/-73 ms. After pulmonary vein isolation and left atrial ablation, AF converted to AT from the SV during right atrial ablation in 2 patients, by rapid atrial pacing after AF termination in 7 patients, and during isoproterenol infusion in 1 patient. Positive P-waves in inferior leads were shown in most patients (90%). The activation sequence of AT was from proximal to distal in the superior vena cava and high to low in the right atrium, which was similar to that of AT from crista terminalis. Fragmented double potentials were recorded during sinus, and a second discrete potential preceded the onset of P wave by 80+/-37 ms during AT. Using 4.4+/-2.7 radiofrequency focal applications, ATs were terminated and became no longer inducible in all. After ablation procedure, two patients showed transient right phrenic nerve palsy. After 19.9+/-14.8 months, all but 1 patient were free of atrial tachyarrhythmia without complications.
CONCLUSION
The AT which develops during AF ablation is rarely originated from SV, and its electrophysiologic characteristics may be helpful in guiding effective focal ablation.

Keyword

Atrial tachycardia; Sinus venosus; Atrial fibrillation

MeSH Terms

Atrial Fibrillation
Catheter Ablation
Catheters
Electrocardiography
Heart Atria
Humans
Isoproterenol
Male
Paralysis
Phrenic Nerve
Pulmonary Veins
Tachycardia
Vena Cava, Superior
Isoproterenol

Figure

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  Fig. 1 A representative example of activation sequence during atrial tachycardia from SV in patient No. 3. Activation sequence was proximal (P) to distal (D) in the SVC and CS and from high to low at the RA. The earliest potential at the distal ablation catheter (ABL) preceded the onset of P wave at surface ECG by 97 ms. CS: coronary sinus, HRA: high right atrium, SV: sinus venosus, SVC: superior vena cava, ECG: electrocardiograpy.

• 

  Fig. 2 Double potentials were recorded during sinus (A), and a second discrete potential (*) preceded the onset of P wave during atrial tachycardia by mean of 80±37 ms (B). ABL: ablation catheter, HRA: high right atrium, CS: coronary sinus, AT: atrial tachycardia.

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  Fig. 3 Patient No. 4 showed 2 : 1 conduction potentials from the SV (*) to other areas. SV: sinus venosus, ABL: ablation catheter, HRA: high right atrium, CS: coronary sinus.

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  Fig. 4 RA activation mapping revealed that the earliest activation site (white arrow) was SV. RA: right atrium, SV: sinus venosus.

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  Fig. 5 Effects of radiofrequency ablation. Radiofrequency energy delivery at the SV slowed the tachycardia cycle length from 345 to 355 ms (A) and finally resulted in sinus rhythm within 56 seconds (B). There were no inducible tachycardias thereafter. SV: sinus venosus, RFCA: radiofrequency catheter ablation, ABL: ablation catheter, HRA: high right atrium, CS: coronary sinus.

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  Fig. 6 A representative example of fluoroscopic and three-dimensional images of the ablation site, SV (white arrow). Right-anterior oblique projection view 35° (A); left-anterior oblique projection view 35° (B); and three-dimensional images, white arrow and yellow dot indicates SV where AT terminated during RF application (C). ABL: ablation catheter, CS: coronary sinus, HRA: high right atrium, RF: radiofrequency, SV: sinus venosus, SVC: superior vena cava, AT: atrial tachycardia.

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