1. Circ Arrhythm Electrophysiol
Catheter Ablation of Multiple Unstable Macroreentrant Tachycardia Within the Right Atrium Free Wall in Patients Without Previous Cardiac SurgeryCLINICAL PERSPECTIVE
by Kazuhiro Satomi, K.R. Julian Chun, Roland Tilz, Dietmar Bänsch, Sabine Ernst, Matthias Antz, Boris Schmidt, Karl-Heinz Kuck, and Feifan Ouyang
Circ Arrhythm Electrophysiol
Volume 3(1):24-31
February 1, 2010
Copyright © American Heart Association, Inc. All rights reserved.

2. Figure 1. Schematic representation of ablation lines at the RAFW
Figure 1. Schematic representation of ablation lines at the RAFW. If the AES extended toward the crista terminalis, a linear lesion between the superior region of the AES and the tricuspid annulus, a linear lesion between the inferior region of the AES and the IVC and a cavo-tricuspid isthmus line were created to close the RAFW (“complex lesions” pattern).
Figure 1. Schematic representation of ablation lines at the RAFW. If the AES extended toward the crista terminalis, a linear lesion between the superior region of the AES and the tricuspid annulus, a linear lesion between the inferior region of the AES and the IVC and a cavo-tricuspid isthmus line were created to close the RAFW (“complex lesions” pattern). If the AES was limited to the RAFW, RF applications were delivered in a circular pattern at the RAFW including low potential areas or identifiable isthmuses of tachycardias according to the electroanatomic map (“circumferential lesion” pattern). SVC indicates superior vena cava; TA, tricuspid annulus; RAO, right anterior oblique.
Kazuhiro Satomi et al. Circ Arrhythm Electrophysiol. 2010;3:24-31
Copyright © American Heart Association, Inc. All rights reserved.

3. Figure 2. Twelve-lead ECG of pleomorphic ATs
Figure 2. Twelve-lead ECG of pleomorphic ATs. Six types of ATs were induced in 1 patient in group B. All ATs had different CLs.
Figure 2. Twelve-lead ECG of pleomorphic ATs. Six types of ATs were induced in 1 patient in group B. All ATs had different CLs.
Kazuhiro Satomi et al. Circ Arrhythm Electrophysiol. 2010;3:24-31
Copyright © American Heart Association, Inc. All rights reserved.

4. Figure 3. Twelve-lead ECG of unstable AT
Figure 3. Twelve-lead ECG of unstable AT. Morphology of P wave and CL of AT were changing during mapping in a patient in group B.
Figure 3. Twelve-lead ECG of unstable AT. Morphology of P wave and CL of AT were changing during mapping in a patient in group B.
Kazuhiro Satomi et al. Circ Arrhythm Electrophysiol. 2010;3:24-31
Copyright © American Heart Association, Inc. All rights reserved.

5. Figure 4. Twelve-lead ECG and activation map during tachycardia.
Figure 4. Twelve-lead ECG and activation map during tachycardia. Electroanatomic activation mapping during an AT in a patient in group A demonstrated the exit at the superior part of the AES at the RAFW and the entrance at the inferior part. This tachycardia was terminated by applications at the exit region. The duration obtained by the activation map covered only 56% of AT CL (189 of 340 ms). This indicated that most of the slow conduction zone was located in the AES.
Kazuhiro Satomi et al. Circ Arrhythm Electrophysiol. 2010;3:24-31
Copyright © American Heart Association, Inc. All rights reserved.

6. Figure 5. Voltage map and RF application in patients with AT with no identified isthmus in group B. The electroanatomic voltage maps of the RA during SR showed the AES at the RAFW, indicated by the gray area.
Figure 5. Voltage map and RF application in patients with AT with no identified isthmus in group B. The electroanatomic voltage maps of the RA during SR showed the AES at the RAFW, indicated by the gray area. Note multiple scattered AES located on RAFW, extending from the tricuspid annulus to the crista terminalis in the left panel. The right panel shows the voltage map of another patient with extensive AES at the RAFW. Low-voltage areas were demonstrated around the AES in both patients. Two ablation lines were created to connect the free wall AES and anatomic obstacles (“complex lesions” pattern), such as AES to tricuspid annulus and scar to IVC. This patient had prior cavo-tricuspid isthmus block (left panel). An encircling lesion was attempted around the free wall AES (“circumferential lesion” pattern) (right panel). Red dots indicate the point of applications.
Kazuhiro Satomi et al. Circ Arrhythm Electrophysiol. 2010;3:24-31
Copyright © American Heart Association, Inc. All rights reserved.

7. Figure 6. Intracardiac recording at the time of RAFW isolation.
Figure 6. Intracardiac recording at the time of RAFW isolation. The electrogram recorded by 20-polar catheter shows sudden elimination of signal (star) during RF application at the RAFW region, indicating the electric isolation of the RAFW. Note low amplitude before isolation on almost all RAFW bipoles suggestive of scar. RA indicates RAFW; CS, coronary sinus; MAPp, mapping/ablation catheter proximal; MAPd, mapping/ablation catheter distal.
Kazuhiro Satomi et al. Circ Arrhythm Electrophysiol. 2010;3:24-31
Copyright © American Heart Association, Inc. All rights reserved.

8. Figure 7. Flow chart showing the result of ablation and follow-up.
Kazuhiro Satomi et al. Circ Arrhythm Electrophysiol. 2010;3:24-31
Copyright © American Heart Association, Inc. All rights reserved.