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Volume 11, Issue 1, Pages (January 2014)

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1 Volume 11, Issue 1, Pages 17-25 (January 2014)
Management of focal atrial tachycardias originating from the atrial appendage with the combination of radiofrequency catheter ablation and minimally invasive atrial appendectomy  Xiao-gang Guo, MD, Jin-lin Zhang, MD, Jian Ma, MD, Yu-he Jia, MD, Zhe Zheng, MD, Hong-yue Wang, MD, Xi Su, MD, Shu Zhang, MD, FHRS  Heart Rhythm  Volume 11, Issue 1, Pages (January 2014) DOI: /j.hrthm Copyright © 2014 Heart Rhythm Society Terms and Conditions

2 Figure 1 Electroanatomical activation mapping: (A) right atrial appendage; (B) left atrial appendage. Early electrograms are depicted in red, late electrograms in purple, and electrograms in between by shades of color as shown in the reference color bar. Red and yellow dots were the sites at which ablations were attempted. LAO = left anterior oblique; RAO = right anterior oblique. Heart Rhythm  , 17-25DOI: ( /j.hrthm ) Copyright © 2014 Heart Rhythm Society Terms and Conditions

3 Figure 2 Atrial appendage morphologies. The morphologies of the LAA can be divided into cactus (A), chicken wing (B), wind sock (C), and cauliflower (D). The morphologies of the right atrial appendage, which were comparatively conservative, can be classified as those with a long lower lobe (G and H) and those without (E and F). The silhouettes of appendages are delineated by white broken lines. White solid lines, which intersect the transition zone of less trabeculated area and highly trabeculated area, divide the atrial appendage into proximal and distal portions. LAO = left anterior oblique; RAO = right anterior oblique. Heart Rhythm  , 17-25DOI: ( /j.hrthm ) Copyright © 2014 Heart Rhythm Society Terms and Conditions

4 Figure 3 Anatomical variances and anomalies of the right atrial appendage. A and B: A right atrial diverticulum (solid arrow head) was coincidentally detected in juxtaposition with the right atrial appendage (RAA). C and D: The delta-shaped RAA in diastole (panel D) turned to be clover shaped in systole (panel C), and several pouches (solid arrow) implied abundant but unevenly distributed pectinates. LAO = left anterior oblique; RAO = right anterior oblique. Heart Rhythm  , 17-25DOI: ( /j.hrthm ) Copyright © 2014 Heart Rhythm Society Terms and Conditions

5 Figure 4 Fluoroscopy of distal AATs. The ablation catheters in the distal portion of the right atrial appendage (A) and that of the left atrial appendage (B) were confirmed by selective atrial appendage angiography. The silhouettes of appendages are delineated by broken lines. ABL = ablation catheter; CS = coronary sinus; LAO = left anterior oblique; Lasso = circular catheter; RAO = right anterior oblique; RVA = right ventricular apex. Heart Rhythm  , 17-25DOI: ( /j.hrthm ) Copyright © 2014 Heart Rhythm Society Terms and Conditions

6 Figure 5 Fluoroscopy of proximal atrial appendage tachycardias. The ablation catheters in the proximal portion of the left atrial appendage (A) and that of the right atrial appendage (B) were confirmed by selective atrial appendage angiography. The silhouettes of appendages are delineated by broken lines. ABL = ablation catheter; CS = coronary sinus; HBE = His bundle electrogram; LAO = left anterior oblique; RAO = right anterior oblique; RVA = right ventricular apex. Heart Rhythm  , 17-25DOI: ( /j.hrthm ) Copyright © 2014 Heart Rhythm Society Terms and Conditions

7 Figure 6 Video-assisted thoracoscopy atrial appendectomy. A: The left atrial appendage was partly detached from the atrium with the clip seen at the base. B: Atrial tachycardia was immediately terminated on the excision of the atrial appendage. Upper tracing shows electrocardiogram before surgery and lower tracing after surgery. Heart Rhythm  , 17-25DOI: ( /j.hrthm ) Copyright © 2014 Heart Rhythm Society Terms and Conditions

8 Figure 7 Pathohistology. A and B: A transmural lesion was noted with granulation and fibrosis (white solid arrow) next to hemorrhage (black solid arrow) and extracellular edema (yellow solid arrow). C and D: A nontransmural lesion was revealed at the trabecula. Area in the vicinity to the lesion was interspersed with abundant nuclei-absent cells that clustered to form a kidney-shaped figuration (blue broken line). A and C: Masson’s trichrome staining. B and D: Hematoxylin-eosin staining. Endo = endocardium; Epi = epicardium; Trab = trabeculae. Heart Rhythm  , 17-25DOI: ( /j.hrthm ) Copyright © 2014 Heart Rhythm Society Terms and Conditions


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