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1/107. Transcatheter ablation of incessant ectopic left atrial tachycardia using radiofrequency current.

    catheter ablation of ectopic atrial tachycardia has been previously reported in a small number of patients in whom the ectopic focus was predominantly located in the right atrium. We report on a 51-year-old patient with atrial automatic tachycardia originating in the left atrium, in whom successful radiofrequency catheter ablation was performed via a transseptal puncture. The patient had suffered incessant atrial tachycardia for several years, refractory to antiarrhythmic drug treatment and DC-cardioversion. Radiofrequency ablation terminated left ectopic atrial tachycardia and, therefore, should have been attempted before resorting to open heart surgical ablation. ( info)

2/107. Familial association of congenital left heart abnormalities and sustained fetal arrhythmia.

    hypoplastic left heart syndrome (HLHS) is the most common cause of death from heart disease in the first week of life. There are reports about familial concordance by presumed morphogenetic mechanisms of abnormal embryonic blood flow with phenotypes of varying severity. The risk of having a child with a left heart lesion after a previously affected child may be as high as 5% to 12%. We present case reports from four families in which sustained fetal arrhythmia (three ectopic atrial tachycardias and one severe bradycardia due to excessive ectopic atrial beats) was demonstrated. Within these four families a close relative of the mother (a previous child, a brother, or a nephew) had severe left heart abnormality (three with HLHS and one with severe aortic valve stenosis). The association of sustained fetal arrhythmia of ectopic atrial origin and severe left heart abnormalities could be expected to occur by chance in a very low percentage of cases. We conclude that sustained fetal atrial ectopic arrhythmia is a congenital abnormality and should be considered as a risk factor for inherited congenital heart abnormalities. ( info)

3/107. Basket catheter localization of the origin of atrial tachycardia with atypical morphology after atrial flutter ablation.

    Atrial activation from a site in the low lateral right atrium will typically proceed in a superior direction. We present a case of a low lateral right atrial tachycardia with a surface electrocardiographic P wave morphology that appeared to have an inferiorly directed axis. The tachycardia occurred 2 years after successful atrial flutter ablation. The use of a multipolar basket catheter allowed confirmation of the focal origin of the tachycardia, permitted its rapid localization, facilitated catheter ablation, and provided clues to atrial activation that helped describe the appearance of the P wave. ( info)

4/107. Atrial tachycardia as the presenting sign of a left atrial appendage aneurysm.

    A patient presented with atrial tachycardia. The work-up, guided by the tachycardia morphology, led to the diagnosis of left atrial appendage aneurysm. Surgical removal of the atrial appendage resulted in cure of the tachycardia and associated symptoms. ( info)

5/107. temperature-sensitive focal atrial tachycardia in the left atrium.

    temperature sensitivity has not been reported in focal atrial tachycardia. We describe a patient with a left atrial tachycardia whose tachycardia rate was affected by hot and cold drinks. The effects were still evident after autonomic blockade. The arrhythmia focus was located at the entrance of the left upper pulmonary vein. Radiofrequency ablation was carried out, which proved to be difficult, but it was successful after several applications of energy, suggesting an epicardial location of the arrhythmia focus. Sensitivity of atrial tachycardia rate to the temperature of food or drink ingested suggests a left atrial focus with a posterior and possibly epicardial location. ( info)

6/107. Right pulmonary vein potentials recorded from the posterior right atrial endocardium: human case report and validation in a porcine model.

    A 33-year-old woman underwent successful catheter ablation of an atrial tachycardia emanating from deep within a large right superior pulmonary vein (RSPV). A previous ablation attempt in this patient had failed, during which radiofrequency energy applications were made to the posterior right atrium only. The mistaken impression of a right atrial source for this tachycardia was due to RSPV potentials that were recorded during mapping in a region of the posterior right atrium contiguous to the vein ("contiguity region"). To further evaluate this, we performed activation mapping and radiofrequency ablation in atria of healthy pigs. Similar to the reported case, "biatrial" potentials were recorded from both left and right aspects of the contiguity region. Radiofrequency energy application altered only the potential emanating from the atrium in which the lesion was applied. Histologic analysis confirmed that the lesion was limited to this atrium. It is concluded that, due to their proximity, electrical activity in the RSPV may be recorded from certain areas of the posterior right atrium, and vice versa. In the reported case of left atrial tachycardia, this led to the mistaken impression of right atrial tachycardia. ( info)

7/107. Thrombus formation at the site of radiofrequency catheter ablation.

    A 55-year-old woman with a history of resected atrial myxoma with residual patched atrial septal defect (ASD) underwent a successful radiofrequency (RF) ablation of reentry atrial tachycardia. She presented with progressive dyspnea 5 days later. Transesophageal echocardiography revealed a 1-cm right atrial mass attached to the intraatrial septum at the ablation site. Repeat study after anticoagulation for 5 weeks showed complete resolution of the thrombus. Thrombus formation at the site of RF ablation is a potential complication that may require aggressive anticoagulation. patients with patched ASD might be at higher risk. ( info)

8/107. Focal ablation of chaotic atrial rhythm in an infant with cardiomyopathy.

    Chaotic atrial rhythm in infants has been defined similar to multifocal atrial tachycardia in adults, implying a multifocal etiology. However, its ECG appearance resembles atrial fibrillation, which sometimes has a unifocal ectopic mechanism amenable to catheter ablation. Curative focal radiofrequency ablation was performed in a 4-month-old infant with chaotic atrial rhythm and dilated cardiomyopathy. Left ventricular function subsequently returned to normal. Reversibility of associated cardiomyopathy supports aggressive rhythm management of chaotic atrial rhythm. In this patient, the unifocal origin allows insight into the pathophysiology of the rhythm and demonstrates the potential utility of catheter ablation for refractory cases. ( info)

9/107. Atrial tachycardia masquerading as atrial flutter following ablation of the subeustachian isthmus.

    We report a case of atrial tachycardia masquerading as atrial flutter in a man who had previously undergone catheter ablation for atrial flutter. The recurrent arrhythmia was electrocardiographically almost identical to the prior atrial flutter; at repeat electrophysiologic study, although bidirectional conduction block was observed in the tricuspid annulus-inferior vena caval isthmus, the atrial arrhythmia was readily initiated. Activation mapping suggested typical atrial flutter, but entrainment techniques demonstrated intra-atrial reentry not involving the ablated isthmus. This case illustrates the need to apply entrainment techniques even in cases of apparent "typical" atrial flutter to confirm that putative ablation targets are necessary for tachycardia perpetuation. ( info)

10/107. A typical P-wave morphology in incessant atrial tachycardia originating from the right upper pulmonary vein.

    Automatic atrial tachycardias often originate from the ostia of the pulmonary veins. P-wave morphology during tachycardia may indicate from which pulmonary vein the tachycardia originates. Two patients with pulmonary vein tachycardias demonstrating atypical P-wave morphology were investigated. One of the patients had a tachycardia with two different cycle lengths. P-wave morphology was evaluated in 12-lead ECGs from two patients with incessant atrial tachycardia, during tachycardia and sinus rhythm. Their tachycardias were successfully ablated at the mouth of the right upper pulmonary vein. Previous studies have demonstrated a positive or negative P-wave configuration in lead aVL originating from this area and a change from a biphasic P-wave in V1 during sinus rhythm to a positive P-wave configuration during tachycardia. Neither of our two patients had such a change in lead V1. One our patients had two tachycardias with different cycle lengths originating from the same area. It is concluded that if an atrial tachycardia with P-wave morphology resembling that of sinus rhythm cannot be located to the right atrium, its origin may be the right upper pulmonary vein. ( info)
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