Zero-fluoroscopy Radiofrequency Redo Ablation of Atrial Tachycardia Following Pulmonary Vein Isolation: A Tale of Two Systems

Abstract

Regular atrial tachycardia (AT) is one of the most important proarrhythmic complications that may occur following left atrial pulmonary vein isolation (PVI). These tachycardias that develop after atrial fibrillation ablation may lead to worse symptoms than those from the original arrhythmia existing prior to the index ablation procedure. Ablation of various types of supraventricular tachycardias without the use of fluoroscopy has been shown to be feasible in both children and adults using three-dimensional mapping systems. We describe the case of a 71-year-old woman who developed a focal AT after a successful PVI procedure. The initial ablation failed with one mapping system. Repeat electrophysiologic study despite antiarrhythmic medications revealed the same focal AT, which was successfully ablated with a different mapping system. Both ablations were performed without fluoroscopy.

Keywords: Atrial fibrillation; atrial tachycardia; catheter ablation; electroanatomic mapping; zero radiation.

Figure 1:

A: A 12-lead electrocardiogram revealing narrow-complex mid-RP tachycardia with rates of 470 ms. B: Intracardiac electrograms revealing CS9–10 pacing-induced tachycardia, with earliest activation at CS7–8.

Figure 2:

A: Intracardiac electrogram revealing slowing and termination of the tachycardia with ablation of the RSPV. B: CARTO^® 3 (Biosense Webster, Diamond Bar, CA, USA) map of the RA and LA in an anteroposterior top-down position. In the LA, the blue tag represents an ablation point adjacent to the RSPV with termination. In the RA, multiple ablation tags (pink and red) represent ablation points in the posteroseptal area and termination with the red tag. The yellow tag represents the His bundle, whereas the yellow X denotes the transseptal area. RA: right atrium; SVC: superior vena cava; RSPV: right superior pulmonary vein; LSPV: left superior pulmonary vein; LA: left atrium; LIPV: left inferior pulmonary vein; CS: coronary sinus.

Figure 3:

A: A three-dimensional EnSite Precision™ (Abbott Laboratories, Chicago, IL, USA) map of the RA in a posterior view revealing a high density of points. B: A three-dimensional EnSite Precision™ (Abbott Laboratories, Chicago, IL, USA) map of the RA in a posterior view revealing low-voltage (gray) areas at the site of prior ablation. The lone red spot denotes the single 15-second ablation attempt. C: Intracardiac electrogram revealing termination of the AT with restoration of sinus rhythm.