Catheter Ablation of Focal Atrial Tachycardia from the Aortic Cusp: The Role of Electroanatomic Mapping and Intracardiac Echocardiography

Efficacy and Safety of Catheter Ablation of Atrial Tachycardia Through a Direct Approach from Noncoronary Sinus of Valsalva

Noncoronary aortic cusp (NCAC) in the aorta represents a challenging location for catheter ablation of focal atrial tachycardias (ATs) arising near the His-bundle region. The purpose of this study was to provide an updated report on the methods, efficacy, and safety of catheter ablation of ATs originating from NCAC. The study population includes 23 patients (18 women [78%], mean age 65 ± 12 years) with highly symptomatic AT. The atrial mapping was performed during tachycardia to define the earliest atrial activation site. Electrophysiological mapping of the right atrium was initially performed, followed by aortic root mapping when earliest activation was recorded in the proximal electrode of the His-bundle catheter. A direct ablation approach from NCAC was used in every patient independently by the local activation time. Ablations were performed using a steerable 4-mm tip nonirrigated catheter in all patients. Radiofrequency energy resulted in the disappearance of arrhythmias in 22 of the 23 patients (95%). In all procedures, there were no complications. During a mean follow-up of 41 ± 25 months, no patient presented with a recurrence, except the 1 patient where the ablation was not effective. In conclusion, catheter ablation of para-hisian ATs through a direct approach from NCAC shows to be safe and effective after 1 procedure per patient.

Supraventricular Tachycardia in a Patient with an Interrupted Inferior Vena Cava

The noncoronary cusp and aortomitral continuity should be evaluated for early atrial activation when atrial tachycardias are noted to arise near the His bundle region, especially when the activation is diffuse around the His and when the P-wave morphology predicts a left atrial focus. In patients with congenital anomalies, alternate routes for catheter position need to be explored, including retrograde access for left atrial tachycardias and positioning of intracardiac echocardiography in the azygous vein for visualization of intracardiac structures. Consideration of remote magnetic navigation, if available, is another approach.

Should the Aortic Root Be the Preferred Route for Ablation of Focal Atrial Tachycardia Around the AV Node?: Support From Intracardiac Echocardiography

OBJECTIVES

The purpose of this study was to determine the optimal approach to focal atrial tachycardia originating from around the atrioventricular node.

BACKGROUND

Focal atrial tachycardia (FAT) demonstrating earliest activation around the atrioventricular (AV) node during right atrial (RA) mapping has been eliminated by ablation at the RA para-Hisian region, from the left atrium (LA) or the noncoronary aortic cusp (NCC). However the optimal approach has not been determined.

METHODS

We conducted a retrospective analysis of a consecutive series of 148 patients undergoing catheter ablation for FAT between 2006 and 2014 in our institution.

RESULTS

Earliest activation was recorded in the peri-AV nodal region during RA mapping in 34 patients (23%). Of these, 7 patients (20.5%) had successful ablation at the RA septum, using either radiofrequency (n = 4) or cryoenergy (n = 3). Seven FATs (20.5%) were ablated from the LA at the region of the aortomitral continuity, and 20 patients (59%) had successful ablation in the NCC, including 1 patient with a recurrence after a temporarily successful cryoablation from the RA. The proportion of the 3 approaches in this series showed a significant temporal evolution and overall frequency favoring ablation in the NCC (p = 0.011 for time trend and 0.013 for actual vs. expected frequencies). Intracardiac echocardiography proved superior catheter stability with the NCC approach. There were 2 cases of atrioventricular block and 1 recurrence after RA ablation versus no complications or recurrent FAT with NCC and LA approaches.

CONCLUSIONS

Most peri-AV nodal FATs can be safely and effectively ablated from the NCC. The strategy of preferential NCC approach avoids RA para-Hisian ablation with the accompanying risk of AV block.

Atrial tachycardias arising from the atrial appendages and aortic sinus of valsalva

Focal atrial tachycardias arising from the atrial appendages and the aortic sinuses of Valsalva are less frequently encountered in clinical practice. This review article describes the clinical presentation, surface P wave morphology, electrophysiologic characteristics and treatment of these arrhythmias. Catheter ablation of these focal tachycardias has a high success rate. It is however important to be aware of specific anatomic considerations in these locations for optimal treatment outcomes with low complication rates.