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

• Cha MJ
• Kim J
• Park YJ
• Cho MS
• Park HS
• Kwon S
• Lee YS
• Ahn J
• Choi HO
• Park JS
• Hwang Y
• Choi JH
• Hwang KW
• Kim YR
• Han S
• Oh S
• Nam GB
• Choi KJ
• Pak HN

• KMID: 2530732
• DOI: http://doi.org/10.4070/kcj.2021.0388

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

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  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.

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  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.

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  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.

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  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.

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