Coronary sinus reentrant tachycardia after atrial fibrillation ablation: From bad to worse

Pietro Turco

Electrofisiology Laboratory, Multimedica Hospital, Milano, Italia.

DOI: 10.4236/wjcd.2014.42006                

Abstract

Herein we present a case of atrial tachycardia as a sequel of AF ablations. A 42-year-old man was admitted to our department because of a very symptomatic tachycardia. The patient, because of paroxysmal AF and typical atrial flutter, had been already submitted (three times) to ablation procedures in both left (pulmonary vein insulation) and right atria (cavo-tricuspidal isthmus). During the electrophysiological study, a huge and very fast atrial tachycardia was induced: 230 ms cycle length, 1/1 atrio-ventricular conduction with the ventricular rate of 260 bpm, complete left bundle branch block, and clinically recognized by the patient. Four minutes later, a 2/1 AV conduction without branch block permitted mapping and ablation. A high-density mapping around isthmus and coronary sinus (CS) was performed. The analysis of the chronological activation clearly showed a circuit propagation around the CS ostium with a very slow conduction in the anterior zone enlightened by the tight color progression, and counterclockwise activation of the right atrium lateral wall. In anterior zone of CS ostium diastolic fragmented electrograms were detected. After preventing his position localization, radiofrequency delivering (35 W) was effective to interrupt the arrhythmia in 3 seconds. Energy delivering was continued to anchor the lesion to the inferior vena cava. Confirmation of successful ablation was determined by unsuccessful attempts at reinduction of the arrhythmia, in basal state and during infusion of isoproterenol.

Keywords

Atrial Flutter; Atrial Fibrillation; Transcatheter Ablation; Three-Dimensional Mapping

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	De Ponti, R., Verlato, R., Bertaglia, E., Del Greco, M., Fusco, A., Bottoni, N., Drago, F., Sciarra, L., Ometto, R., Mantovan, R. and Salerno-Uriarte, J.A. (2007) Treatment of macroreentrant atrial tachycardia based on electroanatomic mapping: Identification and ablation of the mid-diastolic isthmus. Europace, 9, 449-457. http://dx.doi.org/10.1093/europace/eum055
[2]	Chugh, A., Oral, H., Good, E., Han, J., Tamirisa, K., Lemola, K., Elmouchi, D., Tschopp, D., Reich, S., Igic, P., Bogun, F., Pelosi Jr., F. and Morady, F. (2005) Catheter ablation of atypical atrial flutter and atrial tachycardia within the coronary sinus after left atrial ablation for atrial fibrillation. Journal of the American College of Cardiology, 46, 83-91. http://dx.doi.org/10.1016/j.jacc.2005.03.053
[3]	Chae, S., Oral, H., Good, E., Dey, S., Wimmer, A., Crawford, T., Wells, D., Sarrazin, J.F., Chalfoun, N., Kuhne, M., Fortino, J., Huether, E., Lemerand, T., Pelosi, F., Bogun, F., Morady, F., Chugh, A., et al. (2007) Atrial tachycardia after circumferential pulmonary vein ablation of atrial fibrillation: Mechanistic insights, results of catheter ablation, and risk factors for recurrence. Journal of the American College of Cardiology, 50, 1781-1787. http://dx.doi.org/10.1016/j.jacc.2007.07.044
[4]	Morady, F., Oral H. and Chugh, A. (2009) Diagnosis and ablation of atypical atrial tachycardia and flutter complicating atrial fibrillation ablation. Heart Rhythm, 6, S29-S32. http://dx.doi.org/10.1016/j.hrthm.2009.02.011