Accepted Manuscript Atrial flutter with atypical presentation Vikas Kataria, Amitabh Yaduvanshi, Mohan Nair PII:
S0972-6292(16)30016-X
DOI:
10.1016/j.ipej.2016.07.002
Reference:
IPEJ 69
To appear in:
Indian Pacing and Electrophysiology Journal
Received Date: 24 February 2016 Revised Date:
26 June 2016
Accepted Date: 12 July 2016
Please cite this article as: Kataria V, Yaduvanshi A, Nair M, Atrial flutter with atypical presentation, Indian Pacing and Electrophysiology Journal (2016), doi: 10.1016/j.ipej.2016.07.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title: Atrial Flutter with Atypical Presentation. Short title: Flutter with atypical features Authors:
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1. Dr. Vikas Kataria, MD; Senior Consultant Department of Cardiology, Holy Family Hospital, New Delhi, 110025, India.
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+919818480149,
[email protected] 2. Dr. Amitabh Yaduvanshi, MD;
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Senior Consultant Department of Cardiology, Holy Family Hospital, New Delhi, 110025, India. +9198180794959,
[email protected] 3. Dr. (Prof.) Mohan Nair, MD;
Head of Department of Cardiology, Holy Family Hospital, New Delhi, 110025, India.
Address for Correspondence:
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+919910014371,
[email protected]
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India.
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Dr. (Prof.) Mohan Nair, Head of Department of Cardiology, Holy Family Hospital, New Delhi, 110025,
Tel: +919910014371; Fax: +911126845900, E-mail:
[email protected] Conflict of interest Disclosures: None with any of the author Source of Financial support: None
Keywords: Atrial flutter, counter clockwise atrial flutter, Atypical atrial flutter, focal atrial tachycardia, double loop atrial tachycardia.
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Abbreviations: AT:
Atrial tachycardia
CS:
Coronary sinus
CTI:
Cavo-tricuspid isthmus
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CCW: Counter-clock wise
ECG: Electrocardiogram
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EGM: Electrogram EPS: Electrophysiological study
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Right atrium
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RA:
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Case Report: Brief clinical history: Fifty-five year old lady presented with complaints of recurrent palpitations for last 5 years. She had
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already undergone 3 previous attempts at ablation at another institution; the details of the procedures were not available. Previous cardiac disease or cardiac surgery was absent. Presenting ECG was consistent with counter-clock wise (CCW) atrial flutter (Negative flutter waves in II, III, aVF and positive
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flutter wave in V1) (Figure 1 A).1
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Echo showed mild enlargement of the right atrium (RA) and normal pressure Tricuspid Insufficiency. Electrophysiological Study:
The patient was subjected to electrophsiological study (EPS). Figure 1B shows the electrograms (EGMs) recorded from the coronary sinus (CS) catheter (6F, steerable decapolar catheter, Bard Electrophysiology, Boston, MA, USA) and duo-decapolar catheter (7F, steerable, Livewire™, St. Jude
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Medical, St. Paul, Minn., USA) placed in RA. Atrial activation during flutter was from proximal to distal in the CS and Cranio- Caudal in the duodecapolar catheter suggestive of CCW activation in RA (Figure 1B).
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Mapping with duo-decapolar and ablation catheter showed almost the entire lateral wall to be scarred (Figure 1B, bipoles DD7-8 to DD13-14 hardly record any electrical activity despite good catheter contact
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and therefore have been hidden in the figure). Tachycardia was entrained from the cavo-tricuspid isthmus (CTI) with concealed fusion and post pacing interval within 10 msec of tachycardia cycle length confirming that this site was part of the tachycardia circuit.
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Radiofrequency Ablation: In view of the ECG findings, CCW activation pattern in the duodecapolar recordings and entrainment
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results, ablation at the CTI was started (4mm, irrigated, 50 W, 40 c, 20cc/min).2 Just as the CTI line was being completed, there was a switch in the atrial activation pattern, evident on the surface P waves, without any change in tachycardia cycle Length or the activation sequence on the recording catheters
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(Figure 2A & B).
Entrainment was tried again from both sides of the isthmus and other regions in RA including multiple
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points at crista, but entrainment with concealed fusion was not obtained anywhere (Figure 2C). The tachycardia now behaved more like a focal tachycardia than re-entry, as it was non-entrainable and had a clear isoelectric interval between the P waves.
On the basis of earliest atrial activity during mapping, the origin of the tachycardia was mapped to the
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upper- mid Crista region and was easily ablated by point ablation at this site (Figure 2D). Post restoration of sinus rhythm, CTI isthmus block was confirmed by differential pacing maneuvers. No sustained tachycardia could be induced on atrial pacing maneuvers at basal state and on
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Discussion:
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isoprenaline.
The present case is an example highlighting the challenges faced during ablation of atrial tachycardia. A tachycardia which was initially typical CCW atrial flutter switched to a tachycardia which appeared to be focal in origin arising in the crista terminalis region. Probable mechanisms of the unusual features seen in this complex tachycardia and the points in favor / against of each explanation are given below. The change in P wave morphology is explained by the pre-dominant atrial activation vector in both the possibilities given below:
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Possibility 1: Dual loop tachycardia
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Dual loop reentry tachycardia, is one definite possibility. The initial tachycardia was CCW flutter. Following CTI block the tachycardia continued in the second loop. (Figure 3).3 Points which are difficult to explain on the basis of this possibility:
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tachycardia favors non-reentry rather than a “loop”
b) Inability to entrain the second
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a) Both tachycardias had exactly the same cycle length
Possibility 2: Focal tachycardia driving the Flutter
A focal atrial tachycardia (AT) on the free wall of the right atrium that has induced typical cavotricuspid isthmus dependent flutter and the automatic tachycardia continuously entrains
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and maintains the flutter. Ectopic atrial tachycardia got unmasked after the CTI was blocked (Figure 4).
This is a more plausible explanation, as a) The two tachycardias had the same cycle length, b) The ECG
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features after CTI ablation was that of a focal AT c) the second tachycardia could not be entrained and
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d) It was abolished by a single point ablation. Three dimensional electro-anatomic mapping may have given better insight into the mechanism of the two tachycardias seen in this case. Electro-anatomic mapping is not routinely used for CCW atrial flutter at our center. Whether the complex tachycardia and area of electrical inactivity in the RA could have been due to earlier ablation procedure or an atrial myopathy could be argued. Atrial cardiac MRI was not available at the time of the study. Acknowledgments: None
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References: 1. Saoudi N, Nair M, Abdelazziz A, Poty H, Daou A, Anselme F, Letac B. Electrocardiographic Patterns and Results of Radiofrequency Catheter Ablation of Clockwise Type I Atrial Flutter. Journal of
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Cardiovascular Electrophysiology. 1996; 7: 931–942
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2. Poty H, Saoudi N, Abdel Aziz A, Nair M, Letac B. Radiofrequency catheter ablation of type 1 atrial flutter. Prediction of late success by electrophysiological criteria.Circulation. 1995;92:1389-92. 3. Dipen Shah, Pierre Jaïs, Atsushi Takahashi, MelezeHocini, Jing TianPeng, Jacques Clementy, Michel
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Haïssaguerre. Dual-Loop Intra-Atrial Reentry in Humans. Circulation.2000; 101: 631-639
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Figure Legends: Figure 1:A) ECG at the time of presentation. There is no clear Isoelectric line in III .Note the negative ‘f" waves in inferior leads and isoelectric / biphasic ‘p’ in V1, consistent with CCW flutter. B) Electrogram recordings from the coronary sinus and the duodecapolar catheters in RA (bipoles7-8 to 13-14 have
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been hidden, See text for details). Inset: A static fluoroscopic frame recorded simultaneously shows duodecapolar catheter in the RA, decapolar catheter in CS and ablation catheter. Note that the
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duodecapolar catheter is in good contact with the RA wall.
Figure 2:A) 12 Lead ECG recording during the CTI ablation. Note the change in the p waves from being negative / biphasic (left two arrows) to frankly positive (right two arrows) without any significant change in the cycle length. B) intracardiac electrogram recorded from CS and duodecapolar catheter after the
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change in tachycardia. Note the different p wave morphology but the same electrogram activation compared to figure 1B and C) The second tachycardia could not be entrained from any position in the
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right atrium D) Termination of tachycardia during ablation at crista region. Figure 3: Double loop Tachycardia. A) Two loops of tachycardia B) After CTI ablation: Tachycardia
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continues in single loop
Figure 4:A)Ectopic focus on the free RA wall which initiates and then continuously entrains the CCW flutter B) after CTI ablation: CCW flutter terminates whereas ectopic atrial tachycardia continues.
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Figures:
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Figure 1
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Figure 4
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