High-Density Mapping and Ablation of Primary Nonfocal Left Atrial Tachycardia: Characterizing a Distinct Arrhythmogenic Substrate

TY - JOUR

T1 - High-Density Mapping and Ablation of Primary Nonfocal Left Atrial Tachycardia: Characterizing a Distinct Arrhythmogenic Substrate

AU - Schaeffer, Benjamin

AU - Akbulak, Ruken Ö

AU - Jularic, Mario

AU - Moser, Julia

AU - Eickholt, Christian

AU - Schwarzl, Jana M

AU - Klatt, Niklas

AU - Kuklik, Pawel

AU - Meyer, Christian

AU - Willems, Stephan

N1 - Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

PY - 2019/4

Y1 - 2019/4

N2 - OBJECTIVES: This study sought to characterize primary left atrial tachycardia (LAT) mechanisms, electrical properties and substrate using high-density mapping.BACKGROUND: Nonfocal LAT can be found in patients without prior substrate modifying interventions.METHODS: Of 223 catheter ablation procedures for LAT 15 patients (60% male, age 74 ± 6 years) had nonfocal AT and no history of LA ablation or cardiac surgery.RESULTS: AT (mean cycle length 244 ± 32 ms) were identified as macro-re-entry (12 of 15) or localized re-entry (3 of 15). High-density electroanatomical mapping (EAM, performed in 13 patients) revealed a high proportion of low voltage areas (LVA, <0.45 mV, 41 ± 22%). Anterior LVA regions were predominantly related to the macro-re-entry and directly perpetuating the re-entrant circuit in 8 patients by formation of a conductive channel (width: 14 ± 7 mm, length: 11 ± 3 mm) between the inferior pole of the scar and the mitral valve (MV) annulus with electrophysiological features of diseased tissue. A tailored anterior ablation line successfully terminated AT in 9 patients (6 dominant circuit MV dependent, 3 dominant circuit scar dependent AT), while a lateral isthmus line was performed in 2 patients. Localized re-entries were successfully targeted by local ablation. Acute successful ablation could be achieved in 14 of 15 patients leading to a freedom from any arrhythmias in 9 of 15 patients (60%) after follow-up of 343 ± 203 days.CONCLUSIONS: Patients with nonfocal left atrial tachycardia without previous iatrogenic interventions show evidence for advanced atrial myopathy. High-density mapping revealed involvement of the anterior LA and allows for an individualized ablation approach beyond strategies usually applied in consecutive AT.

AB - OBJECTIVES: This study sought to characterize primary left atrial tachycardia (LAT) mechanisms, electrical properties and substrate using high-density mapping.BACKGROUND: Nonfocal LAT can be found in patients without prior substrate modifying interventions.METHODS: Of 223 catheter ablation procedures for LAT 15 patients (60% male, age 74 ± 6 years) had nonfocal AT and no history of LA ablation or cardiac surgery.RESULTS: AT (mean cycle length 244 ± 32 ms) were identified as macro-re-entry (12 of 15) or localized re-entry (3 of 15). High-density electroanatomical mapping (EAM, performed in 13 patients) revealed a high proportion of low voltage areas (LVA, <0.45 mV, 41 ± 22%). Anterior LVA regions were predominantly related to the macro-re-entry and directly perpetuating the re-entrant circuit in 8 patients by formation of a conductive channel (width: 14 ± 7 mm, length: 11 ± 3 mm) between the inferior pole of the scar and the mitral valve (MV) annulus with electrophysiological features of diseased tissue. A tailored anterior ablation line successfully terminated AT in 9 patients (6 dominant circuit MV dependent, 3 dominant circuit scar dependent AT), while a lateral isthmus line was performed in 2 patients. Localized re-entries were successfully targeted by local ablation. Acute successful ablation could be achieved in 14 of 15 patients leading to a freedom from any arrhythmias in 9 of 15 patients (60%) after follow-up of 343 ± 203 days.CONCLUSIONS: Patients with nonfocal left atrial tachycardia without previous iatrogenic interventions show evidence for advanced atrial myopathy. High-density mapping revealed involvement of the anterior LA and allows for an individualized ablation approach beyond strategies usually applied in consecutive AT.

KW - Aged

KW - Aged, 80 and over

KW - Catheter Ablation

KW - Electrophysiologic Techniques, Cardiac

KW - Female

KW - Heart Atria/physiopathology

KW - Humans

KW - Male

KW - Prospective Studies

KW - Tachycardia/diagnosis

U2 - 10.1016/j.jacep.2019.02.002

DO - 10.1016/j.jacep.2019.02.002

M3 - SCORING: Journal article

C2 - 31000095

VL - 5

SP - 417

EP - 426

JO - JACC-CLIN ELECTROPHY

JF - JACC-CLIN ELECTROPHY

SN - 2405-500X

IS - 4

ER -