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• W1736763703 abstract "A 38-year-old man without any structural heart disease underwent a third ablation procedure for recurrent persistent atrial tachycardia (AT). He had undergone pulmonary vein (PV) isolation and cavotricuspid isthmus ablation for symptomatic, drug-refractory paroxysmal atrial fibrillation at our institute in the first and second procedures 3 years earlier. The starting rhythm in the third procedure was a stable AT with a cycle length of 210 ms. No PV reconnections were observed. Activation mapping using a 3-D mapping system (CARTO3, Biosense Webster, Diamond Bar, CA) and entrainment mapping revealed that the mechanism of the AT was a dual AT, which was a combination of a left atrial (LA) roof-dependent AT and perimitral atrial tachycardia (PMAT). A roofline ablation produced double potentials along the ablation line, and the AT cycle length prolonged to 220 ms. Subsequent linear ablation between the mitral annulus and left PVs from the endocardium, and ablation inside the coronary sinus (CS) resulted in further prolongation of the AT cycle length to 240 ms. However, the AT was still sustained. Repeated activation and entrainment mapping still showed that AT mechanism was PMAT. The AT was terminated by electrical cardioversion to identify the conduction gaps along the mitral isthmus (MI) line. After cardioversion, LA roofline block was confirmed by pacing maneuvers. The intracardiac tracing during pacing from the left atrial appendage (LAA) and those from differential pacing are shown in Figure 1, Figure 1. Did the PMAT pass through a completely blocked MI line, or was the diagnosis of the AT mechanism incorrect? During pacing from one side of the MI line, the wavefront reaches the other side of the line last when complete MI block has been established.1Jais P. Hocini M. Hsu L.F. Sanders P. Scavee C. Weerasooriya R. Macle L. Raybaud F. Garrigue S. Shah D.C. Le Metayer P. Clémenty J. Haïssaguerre M. Technique and results of linear ablation at the mitral isthmus.Circulation. 2004; 110: 2996-3002Crossref PubMed Scopus (640) Google Scholar Therefore, proximal-to-distal CS activation should be observed during pacing from the LAA. For evaluation of complete linear block, a differential pacing technique is necessary to distinguish slow conduction across the MI from complete block.2Shah D. Haissaguerre M. Takahashi A. Jais P. Hocini M. Clementy J. Differential pacing for distinguishing block from persistent conduction through an ablation line.Circulation. 2000; 102: 1517-1522Crossref PubMed Scopus (206) Google Scholar In the present case, proximal-to-distal CS activation during pacing from the LAA with conduction delay of 176 ms to CS1-2 was observed (Figure 1A). Pacing from CS1-2, which was positioned close to the line, prolonged the conduction time to the LAA more than that during pacing from CS3-4. Figure 1B shows conduction delay to the LAA of 164, 142, and 128 ms during CS1-2, CS3-4, and CS5-6 pacing, respectively (Figure 1B). These findings suggest that bidirectional conduction block was already created before electrical cardioversion. Why was the PMAT sustained in this situation? The important point to note is the tiny signals recorded on the catheter placed at CS1-2 in Figure 1A, in which all signals were recorded with the same amplitude. Figure 2A shows the same tracing as in Figure 1A with amplified bipolar signals from the distal CS. Now, small signals (Figure 2A, red arrow, 0.049 mV) are recognized, and those potentials likely are far-field potentials from the LA. Increasing the pacing output (from 10 mA, 2 ms to 15 mA, 2 ms) during pacing from CS1-2 resulted in a significantly short conduction time (Figure 2B). It is likely that the low-output pacing captured only the CS potentials and the high-output pacing captured both the CS and LA potentials. Those patterns indicate pseudo-MI block.3Shah A.J. Pascale P. Miyazaki S. Liu X. Roten L. Derval N. Jadidi A.S. Scherr D. Wilton S.B. Pedersen M. Knecht S. Sacher F. Jaïs P. Haïssaguerre M. Hocini M. Prevalence and types of pitfall in the assessment of mitral isthmus linear conduction block.Circ Arrhythm Electrophysiol. 2012; 5: 957-967Crossref PubMed Scopus (47) Google Scholar In the present case, further radiofrequency applications from the endocardium during pacing from the LAA resulted in transient MI block (Figure 3A); however, it did not result in persistent conduction block even under a high contact force (>30–50g; Smarttouch, Biosense Webster) with the support of a deflectable sheath. A subsequent radiofrequency application inside the CS at a site close to the transient successful site (10 mm apart) resulted in persistent MI block (Figure 3B). The MI line joins the mitral annulus to the PV either anteriorly or laterally.1Jais P. Hocini M. Hsu L.F. Sanders P. Scavee C. Weerasooriya R. Macle L. Raybaud F. Garrigue S. Shah D.C. Le Metayer P. Clémenty J. Haïssaguerre M. Technique and results of linear ablation at the mitral isthmus.Circulation. 2004; 110: 2996-3002Crossref PubMed Scopus (640) Google Scholar Creating complete linear block is essential to prevent recurrent PMAT but is challenging because of the tissue thickness, anatomic complexity, catheter instability, and myocardial sleeves connecting the LA to the CS. Furthermore, the diagnosis of complete linear block is sometimes challenging because of the small potentials and tissue edema after extensive ablation in that area.3Shah A.J. Pascale P. Miyazaki S. Liu X. Roten L. Derval N. Jadidi A.S. Scherr D. Wilton S.B. Pedersen M. Knecht S. Sacher F. Jaïs P. Haïssaguerre M. Hocini M. Prevalence and types of pitfall in the assessment of mitral isthmus linear conduction block.Circ Arrhythm Electrophysiol. 2012; 5: 957-967Crossref PubMed Scopus (47) Google Scholar Missing tiny signals leads to an incorrect diagnosis, and a significant conduction delay could lead to recurrent PMAT.4Miyazaki S. Shah A.J. Hocini M. Haïssaguerre M. Jaïs P. Recurrent spontaneous clinical perimitral atrial tachycardia in the context of atrial fibrillation ablation.Heart Rhythm. 2015; 12: 104-110Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar The present case highlights the importance of a careful diagnosis of complete MI block." @default.
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• W1736763703 date "2015-09-01" @default.
• W1736763703 modified "2023-10-04" @default.
• W1736763703 title "Perimitral atrial tachycardia passing through a completely blocked mitral isthmus line?" @default.
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• W1736763703 doi "https://doi.org/10.1016/j.hrthm.2015.05.002" @default.
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