Abstract
Ablation of typical atrial flutter can be challenging and in many cases is due to difficult anatomy of the cavotricuspid isthmus (CTI). We discuss a case in which we describe how we identified and approached ablation in a patient with a pouch along the CTI and also provide additional information about how to approach challenging anatomy.
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Abbreviations
- CTI:
-
Cavotricuspid isthmus
- ICE:
-
Intracardiac echocardiography
- IVC:
-
Inferior vena cava
- RA:
-
Right atrium
- RF:
-
Radiofrequency
References
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Gami AS, Edwards WD, Lachman N, Friedman PA, Talreja D, Munger TM, et al. Electrophysiological anatomy of typical atrial flutter: the posterior boundary and causes for difficulty with ablation. J Cardiovasc Electrophysiol. 2010;21(2):144–9.
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1 Electronic Supplementary Materials
Intracardiac ultrasound (ICE) image of the ablation catheter positioned parallel to the cavotricuspid isthmus (CTI) and pulled back from the tricuspid valve to the mid CTI. Note the recess or pouch in the mid portion of the CTI is visualized on the ICE images. The angle of approach with the ablation catheter does not allow good contact with the myocardium within the pouch (AVI 187395 kb)
ICE image showing the alternative approach in which the ablation catheter is tightly curved such that the tip is oriented perpendicular to the pouch and pulled down into the recess to perform ablation with better tissue contact within the pouch (AVI 184323 kb)
Fluoroscopy in the RAO and LAO angulation showing the approach described in Video 43.2 with the ablation catheter curved and the catheter tip directed down towards the isthmus with the tip perpendicular to the tissue. This can be used to approach the pouch but also can be helpful to reach the ventricular side of a prominent Eustachian ridge (AVI 49156 kb)
Fluoroscopy in the RAO and LAO angulation showing the approach described in Video 43.2 with the ablation catheter curved and the catheter tip directed down towards the isthmus with the tip perpendicular to the tissue. This can be used to approach the pouch but also can be helpful to reach the ventricular side of a prominent Eustachian ridge (AVI 28419 kb)
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Field, M.E. (2020). Understanding the Anatomy of the Cavo-Tricuspid Isthmus to Troubleshoot a Challenging Atrial Flutter Ablation. In: Natale, A., Wang, P., Al-Ahmad, A., Estes, N. (eds) Cardiac Electrophysiology. Springer, Cham. https://doi.org/10.1007/978-3-030-28533-3_43
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DOI: https://doi.org/10.1007/978-3-030-28533-3_43
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