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. 2018 Jul 6;7(14):e009223.
doi: 10.1161/JAHA.118.009223.

Slow Potential at the Entrance of the Slow Conduction Zone in the Reentry Circuit of a Verapamil-Sensitive Atrial Tachycardia Originating From the Atrioventricular Annulus

Hiroshige Yamabe  1 , Hisanori Kanazawa  2 , Miwa Ito  2 , Shozo Kaneko  2 , Yusuke Kanemaru  2 , Takuya Kiyama  2 , Kenichi Tsujita  2
Affiliations

Slow Potential at the Entrance of the Slow Conduction Zone in the Reentry Circuit of a Verapamil-Sensitive Atrial Tachycardia Originating From the Atrioventricular Annulus

Hiroshige Yamabe et al. J Am Heart Assoc. .

Abstract

Background: Slow conduction zone in a verapamil-sensitive reentrant atrial tachycardia originating from atrioventricular annulus is composed of calcium channel-dependent tissue. We examined whether there was a slow potential (SP) at the entrance of the slow conduction zone.

Methods and results: We first identified the pacing site from where manifest entrainment and orthodromic capture of the earliest atrial activation site were demonstrated in 40 atrioventricular annulus patients with atrioventricular annulus. Radiofrequency energy was then delivered 2 cm proximal to the earliest atrial activation site in the direction of entrainment pacing site and gradually advanced toward the earliest atrial activation site until atrial tachycardia termination to localize the entrance of the slow conduction zone. Electrogram characteristics were analyzed at successful and unsuccessful ablation sites. During sinus rhythm, SP was observed at all 40 successful sites, but was observed at only 12 unsuccessful sites (P<0.0001). During sinus rhythm, there was no significant difference in electrogram amplitude nor width of atrial electrogram between successful and unsuccessful sites (0.407±0.281 versus 0.487±0.447 mV [P=0.1989] and 37.0±9.2 versus 38.9±8.0 ms [P=0.1773]); however, SP amplitude and width at successful sites were significantly greater than those at unsuccessful sites (0.110±0.049 versus 0.025±0.046 mV [P<0.0001] and 38.8±13.4 versus 8.1±13.2 ms [P<0.0001]). During atrial tachycardia, SP amplitude was significantly attenuated (0.088±0.042 versus 0.110±0.049 mV, P<0.001) and SP width was significantly prolonged (47.8±14.1 versus 38.8±13.4 ms, P<0.0001) at successful sites.

Conclusions: SP was observed during sinus rhythm at the entrance of the slow conduction zone; however, SP amplitude was attenuated and SP width was prolonged during atrial tachycardia, suggesting that SP reflects the characteristics of calcium channel-dependent tissue involved in atrioventricular annulus reentry circuit.

Keywords: atrial tachycardia; catheter ablation; mapping.

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Figures

Figure 1
Figure 1
Schematic drawing of the method for the identification of the entrance of the slow conduction zone (SCZ) using entrainment and ablation techniques. ABL indicates ablation catheter; EAAS, earliest atrial activation site.
Figure 2
Figure 2
Tracing during manifest entrainment by pacing from the high anterolateral right atrium in a patient with atrial tachycardia arising from the vicinity of the atrioventricular node. The electrocardiographic leads I, II, and V1, and electrograms recorded at the high right atrium (HRA), coronary sinus (CS), earliest atrial activation site (EAAS), and His bundle (HB) position are shown. AA indicates atrial electrogram interval; AL‐RAp, proximal site of anterolateral right atrium; AL‐RAd, distal site of anterolateral right atrium; MAPd, distal site of mapping catheter; MAPp, proximal site of mapping catheter; Stim, stimulation.
Figure 3
Figure 3
Isochronal map during atrial tachycardia showing the locations of the earliest atrial activation site (EAAS), ablation (ABL) sites, and the entrainment pacing site (A) and tracing during sinus rhythm (B) in the same patient as in Figure 2. Slow potential (SP) was recorded at the successful ABL site (B, right tracing) but not at the unsuccessful site (B, left tracing). The electrocardiographic leads I, II, and V1, and electrograms recorded at the high right atrium (HRA), coronary sinus (CS), ablation catheter (ABL), and His bundle (HB) position are shown. Asterisk: entrainment pacing site at the high anterolateral right atrium (AL‐RA). MAPd indicates distal site of mapping catheter; MAPp, proximal site of mapping catheter; Stim, stimulation; TA, tricuspid annulus; uni, unipolar electrogram.
Figure 4
Figure 4
Tracing during atrial tachycardia (A) and during radiofrequency energy (RF) application (B) in the same patient as in Figure 2. The electrocardiographic leads I, II, and V1, and electrograms recorded at the high right atrium (HRA), coronary sinus (CS), ablation catheter (ABL), and His bundle (HB) position are shown. ABLd indicates distal site of ablation catheter; ABLp, proximal site of ablation catheter; AL‐RAd, distal site of anterolateral right atrium; AL‐RAp, proximal site of anterolateral right atrium; SP, slow potential; Stim, stimulation.
Figure 5
Figure 5
Tracing during sinus rhythm (A) and during atrial tachycardia (B) at the successful ablation site in the same patient as in Figure 2. The amplitude of the slow potential (SP) was attenuated and the electrogram width of the SP was prolonged during atrial tachycardia (B) compared with the SP during sinus rhythm (A). The electrocardiographic leads I, II, and V1, and electrograms recorded at the high right atrium (HRA), coronary sinus (CS), ablation catheter (ABL), and His bundle (HB) position are shown. ABLd indicates distal site of ablation catheter; ABLp, proximal site of ablation catheter; MAPd, distal site of mapping catheter; MAPp, proximal site of mapping catheter; Stim, stimulation; uni, unipolar electrogram.
Figure 6
Figure 6
Tracing during manifest entrainment by rapid atrial pacing delivered during tachycardia from the high anterolateral right atrium in a patient with atrial tachycardia arising from the atrioventricular annulus other than the atrioventricular node vicinity. The electrocardiographic leads I, II, and V1, and electrograms recorded at the high right atrium (HRA), the earliest atrial activation site (EAAS), coronary sinus (CS), and His bundle (HB) position are shown. AA indicates atrial electrogram interval; AL‐RAd, distal site of anterolateral right atrium; AL‐RAp, proximal site of anterolateral right atrium; HBd, distal site of His bundle; HBp, proximal site of His bundle; MAPd, distal site of mapping catheter; MAPp, proximal site of mapping catheter; Stim, stimulation; uni, unipolar electrogram.
Figure 7
Figure 7
Isochronal map during atrial tachycardia showing the locations of the earliest atrial activation site (EAAS), ablation (ABL) sites, and the entrainment pacing site (A) and tracing at the successful and unsuccessful ABL sites during sinus rhythm (B) in the same patient as in Figure 6. The electrocardiographic leads I, II, and V1, and electrograms recorded at the high right atrium (HRA), ABL site, coronary sinus (CS), and His bundle (HB) position are shown. Asterisk: entrainment pacing site at the high anterolateral right atrium (AL‐RA). ABLd indicates distal site of ablation catheter; ABLp, proximal site of ablation catheter; HBd, distal site of His bundle; HBp, proximal site of His bundle; RAA, right atrial appendage; SP, slow potential; Stim, stimulation, SVC, superior vena cava; TA, tricuspid annulus; uni, unipolar electrogram.
Figure 8
Figure 8
Tracing during sinus rhythm (A) and during atrial tachycardia (B) at the successful ablation site in the same patient as in Figure 6. The electrocardiographic leads I, II, and V1, and electrograms recorded at the high right atrium (HRA), ablation catheter (ABL), coronary sinus (CS), and His bundle position are shown. AA indicates atrial electrogram interval; ABLd, distal site of ablation catheter; ABLp, proximal site of ablation catheter; HBd, distal site of His bundle; HBp, proximal site of His bundle; SP, slow potential; Stim, stimulation; uni, unipolar electrogram.
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