Korean Circ J.  2022 Jul;52(7):513-526. 10.4070/kcj.2021.0388.

Prevalence and Characteristics of Atrial Tachycardia From Noncoronary Aortic Cusp During Atrial Fibrillation Catheter Ablation

Affiliations
  • 1Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
  • 2Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
  • 3Division of Cardiology, Department of Internal Medicine, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
  • 4Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
  • 5Division of Cardiology, Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Korea
  • 6Division of Cardiology, Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
  • 7Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea
  • 8Division of Cardiology, Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
  • 9Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, ST. Vincent’s Hospital, Suwon, Korea
  • 10Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
  • 11Division of Cardiology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea

Abstract

Background and Objectives
Atrial tachycardias (ATs) from noncoronary aortic cusp (NCC) uncovered after radiofrequency ablation for atrial fibrillation (AF) are rarely reported. This study was conducted to investigate the prevalence and clinical characteristics of NCC ATs detected during AF ablation and compare their characteristics with de novo NCC ATs without AF.
Methods
Consecutive patients who underwent radiofrequency catheter ablation for AF were reviewed from the multicenter AF ablation registry of 11 tertiary hospitals. The clinical and electrophysiological characteristics of NCC AT newly detected during AF ablation were compared with its comparators (de novo NCC AT ablation cases without AF).
Results
Among 10,178 AF cases, including 1,301 redo ablation cases, 8 (0.08%) NCC AT cases were discovered after pulmonary vein isolation (PVI; 0.07% in first ablation and 0.15% in redo ablation cases). All ATs were reproducibly inducible spontaneously or with programmed atrial stimulation without isoproterenol infusion. The P-wave morphological features of tachycardia were variable depending on the case, and most cases exhibited 1:1 atrioventricular conduction. AF recurrence rate after PVI and NCC AT successful ablation was 12.5% (1 of 8). Tachycardia cycle length was shorter than that of 17 de novo ATs from NCC (303 versus 378, p=0.012). No AV block occurred during and after successful AT ablation.
Conclusions
Uncommon NCC ATs (0.08% in AF ablation cases) uncovered after PVI, showing different characteristics compared to de-novo NCC ATs, should be suspected irrespective of P-wave morphologies when AT shows broad propagation from the anterior interatrial septum.

Keyword

Atrial fibrillation; Ablation techniques; Tachycardia

Figure

  • Figure 1 Twelve-lead electrocardiography and intracardiac electrocardiograms. (A) AT was spontaneously terminated. It was difficult to discriminate the morphology of P-waves in real time because of overlap with the T wave. (B) AT was induced by rapid atrial pacing with a pacing interval of 280 ms. The earliest activation was recorded at the proximal electrodes of the His-bundle catheter. At this site, the local activation preceded the onset of surface P-wave by 33 ms.AT = atrial tachycardia; aVF = augmented vector foot; aVL = augmented vector left; aVR = augmented vector right; CS = coronary sinus; RA = right atrium; RV = right ventricular.

  • Figure 2 P-wave characteristics during AT. There was no consistent rule on P-wave positivity during AT from the noncoronary cusp. In the majority of cases, leads I, aVL, and V6 did not show negative P-wave.AT = atrial tachycardia; aVF = augmented vector foot; aVL = augmented vector left; aVR = augmented vector right.

  • Figure 3 Successful ablation site. (A) The activation map of atrial tachycardia from the noncoronary cusp showed focal electrical propagation from the anterior interatrial septum. The white arrow indicates the successful ablation site at NCC. (B) Using intracardiac echocardiography, 3 different aortic cusps (NCC, RCC, and LCC) can be visualized on the 3-dimensional electroanatomical mapping image. The white arrow indicates the successful ablation site at NCC. (C) During radiofrequency energy application, the catheter stability inside NCC can be monitored by intracardiac echocardiography. (D, E) The LAO and RAO fluoroscopic images showed that the ablation catheter was placed inside the aortic root with the catheter tip toward the NCC.Ao = aorta; LA = left atrium; LAO = left anterior oblique; LAT = local activation time; LCC = left coronary cusp; NCC = non-coronary cusp; RA = right atrium; RAO = right anterior oblique; RCC = right coronary cusp; RV = right ventricular; RVOT = right ventricular outflow tract.

  • Figure 4 Intracardiac electrograms at a successful Abl site. (A) shows the electrograms recordings of multiple diagnostic and Abl catheters at successful Abl site, which did not recur during long-term follow-up. (B) shows the successful Abl site local atrial electrograms inside NCC on diatal Abl catheter of 5 different NCC AT cases. The asterisk marks indicate atrial electrograms, which are larger than the ventricular electrogram amplitudes. The local atrial electrograms presented sharp biphasic electrograms (a-d) or a long fragmented potential (e).Abl = ablation; CS = coronary sinus; NCC = non-coronary cusp; RA = right atrium.*Atrial electrogram at NCC.


Cited by  1 articles

Rare and Elusive Arrhythmia: Atrial Tachycardia From Noncoronary Aortic Cusp During Catheter Ablation for Atrial Fibrillation
Jae-Sun Uhm
Korean Circ J. 2022;52(7):527-528.    doi: 10.4070/kcj.2022.0137.


Reference

1. Santangeli P, Marchlinski FE. Techniques for the provocation, localization, and ablation of non-pulmonary vein triggers for atrial fibrillation. Heart Rhythm. 2017; 14:1087–1096. PMID: 28259694.
Article
2. Santangeli P, Zado ES, Hutchinson MD, et al. Prevalence and distribution of focal triggers in persistent and long-standing persistent atrial fibrillation. Heart Rhythm. 2016; 13:374–382. PMID: 26477712.
Article
3. Al Rawahi M, Liang JJ, Kapa S, et al. Incidence of left atrial appendage triggers in patients with atrial fibrillation undergoing catheter ablation. JACC Clin Electrophysiol. 2020; 6:21–30. PMID: 31971902.
Article
4. Turagam MK, Atoui M, Atkins D, et al. Persistent left superior vena cava as an arrhythmogenic source in atrial fibrillation: results from a multicenter experience. J Interv Card Electrophysiol. 2019; 54:93–100. PMID: 30259306.
Article
5. Yamada T, Allison JS, McElderry HT, Doppalapudi H, Kay GN. Atrial tachycardia initiating atrial fibrillation successfully ablated in the non-coronary cusp of the aorta. J Interv Card Electrophysiol. 2010; 27:123–126. PMID: 19377878.
Article
6. Ouyang F, Ma J, Ho SY, et al. Focal atrial tachycardia originating from the non-coronary aortic sinus: electrophysiological characteristics and catheter ablation. J Am Coll Cardiol. 2006; 48:122–131. PMID: 16814658.
7. Chokr M, Moura LG, Sousa IB, et al. Catheter ablation of focal atrial tachycardia with early activation close to the his-bundle from the non coronary aortic cusp. Arq Bras Cardiol. 2021; 116:119–126. PMID: 33566975.
8. Beukema RJ, Smit JJ, Adiyaman A, et al. Ablation of focal atrial tachycardia from the non-coronary aortic cusp: case series and review of the literature. Europace. 2015; 17:953–961. PMID: 25236180.
Article
9. Yamada T, Huizar JF, McElderry HT, Kay GN. Atrial tachycardia originating from the noncoronary aortic cusp and musculature connection with the atria: relevance for catheter ablation. Heart Rhythm. 2006; 3:1494–1496. PMID: 17161795.
Article
10. Marchlinski F, Tschabrunn CM, Santangeli P, Kubala M. Clarifying the definition of non-pulmonary vein triggers of atrial fibrillation. JACC Clin Electrophysiol. 2019; 5:1328–1330. PMID: 31753440.
Article
11. Kubala M, Lucena-Padros I, Xie S, et al. P-wave morphology and multipolar intracardiac atrial activation to facilitate nonpulmonary vein trigger localization. J Cardiovasc Electrophysiol. 2019; 30:865–876. PMID: 30834593.
Article
12. Yamabe H, Soejima T, Kajiyama K, et al. Efficacy of catheter ablation from the noncoronary aortic cusp of verapamil-sensitive atrial tachycardia arising near the atrioventricular node. Heart Rhythm. 2021.
Article
13. Tada H, Naito S, Miyazaki A, Oshima S, Nogami A, Taniguchi K. Successful catheter ablation of atrial tachycardia originating near the atrioventricular node from the noncoronary sinus of Valsalva. Pacing Clin Electrophysiol. 2004; 27:1440–1443. PMID: 15511256.
Article
14. Chugh A, Latchamsetty R, Oral H, et al. Characteristics of cavotricuspid isthmus-dependent atrial flutter after left atrial ablation of atrial fibrillation. Circulation. 2006; 113:609–615. PMID: 16461832.
Article
15. Joung B, Lee MH, Kim SS. Successful catheter ablation of atrial tachycardia originating from the non-coronary aortic sinus. Yonsei Med J. 2008; 49:1041–1045. PMID: 19108031.
Article
16. Gami AS, Noheria A, Lachman N, et al. Anatomical correlates relevant to ablation above the semilunar valves for the cardiac electrophysiologist: a study of 603 hearts. J Interv Card Electrophysiol. 2011; 30:5–15. PMID: 21161573.
Article
17. Gami AS, Venkatachalam KL, Friedman PA, Asirvatham SJ. Successful ablation of atrial tachycardia in the right coronary cusp of the aortic valve in a patient with atrial fibrillation: what is the substrate? J Cardiovasc Electrophysiol. 2008; 19:982–986. PMID: 18298513.
Article
18. Barros CBS, Chokr MO, Pisani C, Leite TSB, Avila WS, Scanavacca MI. Catheter ablation of atrial tachycardia on the non-coronary aortic cusp during pregnancy without fluoroscopy. HeartRhythm Case Rep. 2018; 4:566–569. PMID: 30581733.
Article
19. Qin M, Liu X, Jiang WF, Wu SH, Zhang XD, Po S. Vagal response during pulmonary vein isolation: re-recognized its characteristics and implications in lone paroxysmal atrial fibrillation. Int J Cardiol. 2016; 211:7–13. PMID: 26963618.
Article
20. Goff ZD, Laczay B, Yenokyan G, et al. Heart rate increase after pulmonary vein isolation predicts freedom from atrial fibrillation at 1 year. J Cardiovasc Electrophysiol. 2019; 30:2818–2822. PMID: 31670430.
Article
21. Cheung CC, Mori S, Gerstenfeld EP. Iatrogenic atrioventricular block. Card Electrophysiol Clin. 2021; 13:711–720. PMID: 34689898.
Article
22. Wang Z, Ouyang J, Liang Y, et al. Focal atrial tachycardia surrounding the anterior septum: strategy for mapping and catheter ablation. Circ Arrhythm Electrophysiol. 2015; 8:575–582. PMID: 25908691.
Full Text Links
  • KCJ
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr