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ALMENDRAL JESÚS. Resetting and Entrainment of Reentrant Arrhythmias: Part II: Informative Content and Practical Use of These Responses. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:641-61. [DOI: 10.1111/pace.12075] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 11/24/2012] [Indexed: 11/27/2022]
Affiliation(s)
- JESÚS ALMENDRAL
- From the Cardiac Arrhythmia Unit; Grupo Hospital de Madrid; Universidad CEU-San Pablo; Madrid; Spain
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Elsik M, Teh A, Ling LH, Virdee M, Parameshwar J, Fynn SP, Kistler PM. Supraventricular arrhythmias late after orthotopic cardiac transplantation: electrocardiographic and electrophysiological characterization and radiofrequency ablation. Europace 2012; 14:1498-505. [PMID: 22523376 DOI: 10.1093/europace/eus092] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Cardiac transplantation (CTX) is an effective treatment for end-stage heart disease. Cardiac arrhythmias are increasingly recognized and associated with significant morbidity and mortality. We aim to describe the clinical and electrophysiological characteristics of patients with atrial arrhythmias occurring late after CTX. METHODS AND RESULTS Sixteen patients with prior CTX who presented with late atrial arrhythmias for electrophysiological studies (EPS) were identified at two cardiac transplant centres. Among 859 patients, 16 (mean age 52 ± 14 years, 11 of 16 were men) patients underwent EPS for atrial arrhythmias presenting 8.6 ± 5.7 years following CTX. Among 16 patients, 14 underwent cardiac alone and 2 included lung transplantation. There were no cases of cardiac rejection. Arrhythmias were due to counterclockwise cavotricuspid-dependent atrial flutter (AFL) in 10 of 16, atrial tachycardia (AT) in 6 (1 patient had AFL and AT), and 1 due to atrioventricular nodal re-entrant tachycardia. Recipient-donor atrial electrical connection was seen in two of six AT and in no cases of AFL. In two cases, a focal AT was mapped to the remnant atrium conducting 2 : 1 or at variable block to the donor atrium. In four cases a focal/micro re-entrant AT originated within the vicinity of the interatrial suture scar. All cases were successfully ablated with radiofrequency energy; however, one case of AFL required a repeat ablation. Patients remained free of arrhythmia at 34 ± 15 months post-ablation. CONCLUSION Typical AFL and AT are the most frequent supraventricular arrhythmias occurring late following CTX. Focal ATs may originate in low-voltage or border zones immediately adjacent to the atrio-atrial anastomosis. Radiofrequency ablation is an effective treatment strategy with high long-term success.
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Affiliation(s)
- Maros Elsik
- Department of Cardiology, Papworth Hospital NHS Trust, Cambridge, UK
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Atrial flutter after heart transplantation: mechanism and catheter ablation. Transplant Proc 2010; 42:2697-701. [PMID: 20832572 DOI: 10.1016/j.transproceed.2010.04.067] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Accepted: 04/01/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Atrial flutter is a frequent arrhythmia after heart transplantation, but little is known about its mechanism and treatment. We report the results of an electrophysiologic study in patients with atrial flutter after orthotopic heart transplantation, describing its mechanism and demonstrating the acute and long-term efficacy of catheter ablation for treating this arrhythmia. METHODS We included 14 patients with symptomatic atrial flutter after orthotopic heart transplantation. All of them underwent an electrophysiologic study to determine the mechanism of the arrhythmia and catheter ablation when possible. RESULTS Counterclockwise right atrial circuit around the tricuspid annulus involving the cavotricuspid isthmus was demonstrated in 13 patients (86%). Catheter ablation of the isthmus was performed with good acute results in all but 1. During a mean follow-up of 24 ± 17 months, recurrent atrial flutter was documented in 3 patients and atrial fibrillation in 2. In another patient, we demonstrated a left atrial origin. CONCLUSIONS The most common mechanism of atrial flutter in heart transplant recipients is a counterclockwise circuit around the tricuspid annulus involving the cavotricuspid isthmus. Catheter ablation of the isthmus between tricuspid annulus and posterior atrial suture line represents an effective treatment in these patients. This condition may be avoided by changing the surgical technique to a bicaval anastomosis.
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Karim RM, Siddiqui TS, Raible S, Deam AG. Recipient atrial flutter masquerading as donor flutter in a heart transplant recipient. J Heart Lung Transplant 2007; 26:414-6. [PMID: 17403487 DOI: 10.1016/j.healun.2007.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2006] [Revised: 11/30/2006] [Accepted: 01/07/2007] [Indexed: 10/23/2022] Open
Abstract
Atrial flutter is common after orthotopic heart transplantation. We present the case of a patient who presented with atrial flutter on 12-lead electrocardiogram. On invasive electrophysiologic study, the donor heart was found to be in sinus rhythm and the recipient atrium was in flutter, which was dissociated from the donor.
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Affiliation(s)
- Rehan M Karim
- Division of Cardiology, Department of Medicine, University of Louisville, Louisville, Kentucky 40202, USA.
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Stecker EC, Strelich KR, Chugh SS, Crispell K, McAnulty JH. Arrhythmias after orthotopic heart transplantation. J Card Fail 2006; 11:464-72. [PMID: 16105638 DOI: 10.1016/j.cardfail.2005.02.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2004] [Revised: 02/13/2005] [Accepted: 02/16/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Arrhythmias frequently occur after orthotopic heart transplantation (OHT). METHODS AND RESULTS The most common are ventricular premature complexes, atrial premature complexes, sinus or junctional bradycardia, atrial fibrillation, and atrial flutter, all of which have varying clinical significance depending on associated or causative conditions. Unique etiologic factors such as allograft rejection, transplant coronary artery disease, and altered anatomy and autonomic nervous system changes require that arrhythmias be treated differently after OHT compared with the general population. CONCLUSION The potentially severe ramifications of allograft rejection and coronary artery disease make treatment of these disorders in the setting of arrhythmias as important as treating the arrhythmias themselves. At the same time, autonomic denervation and altered anatomy after transplantation complicate drug and device therapies.
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Affiliation(s)
- Eric C Stecker
- Department of Cardiology, Oregon Health & Science University, Portland, 97201, USA
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Marine JE, Schuger CD, Bogun F, Kalahasty G, Arnaldo F, Czerska B, Krishnan SC. Mechanism of Atrial Flutter Occurring Late After Orthotopic Heart Transplantation with Atrio-atrial Anastomosis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28:412-20. [PMID: 15869673 DOI: 10.1111/j.1540-8159.2005.40019.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We sought to better define the electrophysiologic mechanism of atrial flutter in patients after heart transplantation. BACKGROUND Atrial flutter is a recognized problem in the post-cardiac transplant population. The electrophysiologic basis of atrial flutter in this patient population is not completely understood. METHODS Six patients with cardiac allografts and symptoms related to recurrent atrial flutter underwent diagnostic electrophysiologic study with electroanatomic mapping and radiofrequency catheter ablation. Comparison was made with a control non-transplant population of 11 patients with typical counterclockwise right atrial flutter. RESULTS In each case, mapping showed typical counterclockwise activation of the donor-derived portion of the right atrium, with concealed entrainment shown upon pacing in the cavotricuspid isthmus (CTI). The anastomotic suture line of the atrio-atrial anastomosis formed the posterior barrier of the reentrant circuit. Ablation of the electrically active, donor-derived portion of the CTI was sufficient to terminate atrial flutter and render it noninducible. Comparison with the control population showed that the electrically active portion of the CTI was significantly shorter in patients with transplant-associated flutter and that ablation was accomplished with the same or fewer radiofrequency lesions. CONCLUSIONS Atrial flutter in cardiac transplant recipients is a form of typical counterclockwise, isthmus-dependent flutter in which the atrio-atrial anastomotic suture line forms the posterior barrier of the reentrant circuit. Ablation in the donor-derived portion of the CTI is sufficient to create bidirectional conduction block and eliminate this arrhythmia. Ablation or surgical division of the donor CTI at the time of transplantation could prevent this arrhythmia.
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Affiliation(s)
- Joseph E Marine
- Henry Ford Heart and Vascular Institute, Detroit, Michigan 48202, USA
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Heist EK, Doshi SK, Singh JP, Di Salvo T, Semigran MJ, Reddy VY, Keane D, Ruskin JN, Mansour M. Catheter Ablation of Atrial Flutter after Orthotopic Heart Transplantation. J Cardiovasc Electrophysiol 2004; 15:1366-70. [PMID: 15610280 DOI: 10.1046/j.1540-8167.2004.04440.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Atrial arrhythmias, including atrial flutter, are common in orthotopic heart transplant recipients. However, only a small number of individual case reports describe the electrical circuit and catheter ablation of atrial flutter after heart transplantation. METHODS AND RESULTS Detailed electrophysiologic evaluation and radiofrequency ablation of atrial flutter were performed in three patients after orthotopic heart transplantation. All cases involved a counterclockwise flutter circuit around the tricuspid annulus. All were successfully ablated at the isthmus between the tricuspid valve and the atrial anastomosis adjacent to the inferior vena cava. CONCLUSION Atrial flutter involving a counterclockwise circuit around the tricuspid annulus is common in the heart transplant population. Based on the patients described in this study and other cases reported in the literature, this arrhythmia often is treated successfully by ablation of the isthmus between the tricuspid valve and the atrial anastomosis near the inferior vena cava.
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Affiliation(s)
- E Kevin Heist
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
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Hadian D, Leier CV. Electroanatomic and electrographic characterization of atrial flutter following cardiac transplantation: Pre- and post-ablation. J Heart Lung Transplant 2004; 23:1205-8. [PMID: 15477116 DOI: 10.1016/j.healun.2003.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2003] [Revised: 08/22/2003] [Accepted: 08/22/2003] [Indexed: 11/18/2022] Open
Abstract
A 20 year-old man developed recurrent symptomatic atrial flutter 9 years following cardiac transplantation. The clinical and electrophysiologic evaluations before and following successful ablation of the atrial flutter form the basis of this report.
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Affiliation(s)
- Djavid Hadian
- Division of Cardiology, Department of Medicine, The Ohio State University Medical Center, Columbus, Ohio, USA
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Magnano AR, Garan H. Catheter ablation of supraventricular tachycardia in the transplanted heart: a case series and literature review. Pacing Clin Electrophysiol 2003; 26:1878-86. [PMID: 12930504 DOI: 10.1046/j.1460-9592.2003.00284.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Clinically important supraventricular arrhythmias are occasionally encountered in patients following cardiac transplantation and the use of catheter ablation as a treatment has been reported. The following three cases are described: (1) atrial flutter, including electroanatomic mapping of the donor and recipient components of the right atrium, (2) a mid-septal accessory pathway, and (3) atrioventricular nodal reentrant tachycardia (AVNRT). A Medline database search was performed and articles addressing catheter ablation following cardiac transplantation were reviewed. The efficacy of RFA for treating various arrhythmia mechanisms was evaluated based on a summary of published case reports.
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Affiliation(s)
- Anthony R Magnano
- Division of Cardiology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Abstract
Atrial arrhythmias have been reported after congenital heart surgery involving extensive atrial suture lines. Experimental studies involving bilateral lung transplantation (Tx) suggest that the left atrial suture lines predispose to atrial flutter. The overall incidence and type of arrhythmias after pediatric lung Tx have not previously been described and therefore the purpose of this study was to prospectively screen and describe arrhythmias in a subset of our lung transplant population. Over a 1-yr study period, all recipients of bilateral lung Tx were admitted to a full-disclosure telemetry unit. Single-lead electrocardiograms were recorded continuously and reviewed daily via a beat-by-beat analysis. A total of 314 patient days (range 9-93, median 43 days) were recorded from seven patients. The incidence of arrhythmias observed per total patient days included junctional escape rhythm (4.8%), non-sustained ventricular tachycardia (4.1%), accelerated junctional (2.5%), sinus bradycardia (2.2%), non-sustained supraventricular tachycardia (1.3%), ectopic atrial tachycardia (1.0%), sustained ventricular tachycardia (0.3%), junctional ectopic tachycardia (0.3%), and second degree heart block (0.3%). No patient had sustained supraventricular tachycardia, atrial flutter, atrial fibrillation, or complete heart block. Arrhythmias were treated in two patients. During the follow-up period, one patient received amiodarone for ventricular tachycardia (which was also noted and treated prior to transplant). We conclude that among pediatric lung transplant recipients admitted for their transplant surgery, arrhythmia is uncommon and rarely requires therapy.
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Affiliation(s)
- T M Hoffman
- Division of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, 34th and Civic Center Blvd., Philadelphia, PA 19104, USA
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Compton SJ, Strobel GG. Sesquiflutter. J Cardiovasc Electrophysiol 1999; 10:1557-8. [PMID: 10571376 DOI: 10.1111/j.1540-8167.1999.tb00215.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- S J Compton
- Division of Cardiology, University of Utah Health Sciences Center, Salt Lake City 84132, USA.
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Arenal A, Almendral J, Alday JM, Villacastín J, Ormaetxe JM, Sande JL, Perez-Castellano N, Gonzalez S, Ortiz M, Delcán JL. Rate-dependent conduction block of the crista terminalis in patients with typical atrial flutter: influence on evaluation of cavotricuspid isthmus conduction block. Circulation 1999; 99:2771-8. [PMID: 10351971 DOI: 10.1161/01.cir.99.21.2771] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The crista terminalis (CT) has been identified as the posterior boundary of typical atrial flutter (AFL) in the lateral wall (LW) of the right atrium (RA). To study conduction properties across the CT, rapid pacing was performed at both sides of the CT after bidirectional conduction block was achieved in the cavotricuspid isthmus by radiofrequency catheter ablation. METHODS AND RESULTS In 22 patients (aged 61+/-7 years) with AFL (cycle length, 234+/-23 ms), CT was identified during AFL by double electrograms recorded between the LW and posterior wall (PW). After the ablation procedure, decremental pacing trains were delivered from 600 ms to 2-to-1 local capture at the LW and PW or coronary sinus ostium (CSO). At least 5 bipolar electrograms were recorded along the CT from the high to the low atrium next to the inferior vena cava. No double electrograms were recorded during sinus rhythm in that area. Complete transversal conduction block all along the CT (detected by the appearance of double electrograms at all recording sites and craniocaudal activation sequence on the side opposite to the pacing site) was observed in all patients during pacing from the PW or CSO (cycle length, 334+/-136 ms), but it was fixed in only 4 patients. During pacing from the LW, complete block appeared at a shorter pacing cycle length (281+/-125 ms; P<0.01) and was fixed in 2 patients. In 3 patients, complete block was not achieved. CONCLUSIONS These data suggest the presence of rate-dependent transversal conduction block at the crista terminalis in patients with typical AFL. Block is usually observed at longer pacing cycle lengths with PW pacing than with LW pacing. This difference may be a critical determinant of the counterclockwise rotation of typical AFL.
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Affiliation(s)
- A Arenal
- Department of Cardiology, Hospital General Universitario Gregorio Marañón Madrid, Spain.
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Pinski SL, Bredikis AJ, Winkel E, Trohman RG. Radiofrequency catheter ablation of atrial flutter after orthotopic heart transplantation: insights into the redefined critical isthmus. J Heart Lung Transplant 1999; 18:292-6. [PMID: 10226892 DOI: 10.1016/s1053-2498(98)00047-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
We report a case of successful radiofrequency catheter ablation of recurrent atrial flutter in a heart transplant recipient and discuss technical aspects of the procedure. A counterclockwise flutter circuit was defined during endocardial mapping of the donor atrium. Termination of atrial flutter was achieved by creating lines of radiofrequency lesions from the tricuspid ring to the suture line between donor and recipient atria. Creation of bidirectional conduction block in the tricuspid ring-suture line isthmus resulted in abolition of atrial flutter.
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Affiliation(s)
- S L Pinski
- Section of Cardiology, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612, USA
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Shah DC, Haïssaguerre M, Jaïs P, Takahashi A, Clémenty J. Atrial flutter: contemporary electrophysiology and catheter ablation. Pacing Clin Electrophysiol 1999; 22:344-59. [PMID: 10087551 DOI: 10.1111/j.1540-8159.1999.tb00449.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- D C Shah
- Hôpital Cardiologique du Haut-Lévêque, Bordeaux-Pessac, France
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