Surface electrocardiogram characteristics of atrial tachycardias occurring after pulmonary vein isolation

Abstract

Objective: The purpose of this study was to describe the surface electrocardiogram (ECG) morphology of common atrial tachycardias (ATs) that occur after pulmonary vein (PV) isolation.

Background: Focal ATs from reconnected PVs and macroreentrant mitral annular (MA) flutter are the most common form of ATs occurring after PV isolation.

Methods: Patients with persistent AT after PV isolation underwent mapping and ablation. Tachycardia origin and mechanism were determined using electroanatomic mapping and entrainment techniques. Patients with typical right atrial flutter occurring after PV isolation were also included for comparison.

Results: Thirty-nine tachycardias were identified in 36 patients, either focal left AT (n = 24) or MA flutter (n = 15). Focal ATs originated from reconnected segments of the right PVs (n = 14) and left PVs (n = 10). MA flutters were counterclockwise (CCL; n = 9) or clockwise (CL; n = 6). Patients with MA flutter had a shorter tachycardia cycle length (239 +/- 7 vs. 259 +/- 34 s; P <.05) than those with focal ATs. CCL MA flutter was positive in the inferior and precordial leads and had a significant negative component in leads I and aVL. CL MA flutter demonstrated the converse limb lead morphology with a significant negative F wave in the inferior leads and positive F wave in leads I and aVL. A negative component in lead I, when present, was best at differentiating CCL MA flutter from left PV ATs, while a positive F wave in lead I was best at differentiating CL MA flutter from CCL right atrial flutter.

Conclusions: There are unique surface ECG characteristics for CL and CCL MA flutter and AT due to reconnected PVs; knowledge of these characteristics may help when planning an ablation strategy.