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Original Articles

Atrial Tachycardia After Ablation of Persistent Atrial Fibrillation

Identification of the Critical Isthmus With a Combination of Multielectrode Activation Mapping and Targeted Entrainment Mapping

Anshul M. Patel, MD, Andre d’Avila, MD, PhD, Petr Neuzil, MD, PhD, Steven J. Kim, MSEE, Theofanie Mela, MD, Jagmeet P. Singh, MD, DPhil, Jeremy N. Ruskin, MD and Vivek Y. Reddy, MD

From the Massachusetts General Hospital, Boston (A.M.P., A.d., T.M., J.P.S., J.N.R., V.Y.R.); Homolka Hospital, Prague, Czech Republic (P.N.); and St. Jude Medical, Minneapolis, Minn (S.J.K.).

Correspondence: Correspondence to Vivek Y. Reddy, MD, Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit St, GRB-109, Boston, MA 02114. E-mail vreddy{at}partners.org

Received November 5, 2007; accepted January 29, 2008.

Background— Atrial tachycardia (AT) that develops after ablation of atrial fibrillation often poses a more difficult clinical situation than the index arrhythmia. This study details the use of an impedance-based electroanatomic mapping system (Ensite NavX) in concert with a specialized multielectrode mapping catheter for rapid, high-density atrial mapping. In this study, this activation mapping was combined with entrainment mapping to eliminate ATs developing late after atrial fibrillation ablation.

Methods and Results— All study patients developed AT after ablation for atrial fibrillation. The approach to AT ablation consisted of 4 steps: use of a 20-pole penta-array catheter to map the chamber rapidly during the rhythm of interest, analysis of the patterns of atrial activation to identify wave fronts of electric propagation, targeted entrainment at putative channels, and catheter ablation at these "isthmuses." All ablations were performed with irrigated radiofrequency ablation catheters. Forty-one ATs were identified in 17 patients (2.4±1.6 ATs per patient). Using the multielectrode catheter in conjunction with the Ensite NavX system, we created activation maps of 33 of 41 ATs (81%) (mean cycle length, 284±71 seconds) with a mean of 365±108 points per map and an average mapping time of 8±3 minutes. Of the 33 mapped ATs, 7 terminated either spontaneously or during entrainment maneuvers. Radiofrequency energy was used to attempt ablation of 26 ATs; 25 of 26 of the ATs (96%) were terminated successfully by ablation or catheter pressure.

Conclusions— This study demonstrates a strategy for rapidly defining and eliminating the scar-related ATs typically encountered after ablation of atrial fibrillation.

Key Words: arrhythmia • ablation • fibrillation • mapping • tachycardia

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CLINICAL PERSPECTIVE

Presented in part at the 2007 Annual Sessions of the Heart Rhythm Society, Denver, Colo, May 9–12, 2007, and published in abstract form (Heart Rhythm. 2007;4:S345).

The online Data Supplement can be found with this article at http://circep.ahajournals.org/cgi/content/full/1/1/14/DC1.

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