Abstract
Background
Despite being increasingly observed in daily practice, epicardial atrial tachycardias (Epi AT) have not been extensively characterized. In the present study, we retrospectively characterize electrophysiological properties, electroanatomic ablation targeting, and outcomes of this ablation strategy.
Methods
Patients who underwent scar-based macro-reentrant left atrial tachycardia mapping and ablation patients with at least one Epi AT, which had a complete endocardial map, were selected for the inclusion. Based on current electroanatomical knowledge, Epi ATs were classified based by utilization of following epicardial structures: Bachmann’s bundle, septopulmonary bundle, vein of Marshall. Endocardial breakthrough (EB) sites were analyzed as well as entrainment parameters. EB site was targeted for initial ablation.
Results
Among seventy-eight patients undergoing scar-based macro-reentrant left atrial tachycardia ablation, fourteen (17.8%) patients met the inclusion criteria for Epi AT and were included in the study. Sixteen Epi ATs were mapped, four utilizing Bachmann’s bundle, five utilizing septopulmonary bundle, and seven utilizing vein of Marshall. Fractionated, low amplitude signals were present at EB sites. Rf terminated the tachycardia in ten patients; activation changed in five patients and in one patient atrial fibrillation ensued. During the follow-up, there were three recurrences.
Conclusions
Epicardial left atrial tachycardias are a distinct type of macro-reentrant tachycardias that can be characterized by activation and entrainment mapping, without need for epicardial access. Endocardial breakthrough site ablation reliably terminates these tachycardias with good long-term success.
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Contributions
Emir Baskovski: conceptualization, methodology, formal analysis, and writing—original draft. Ali Timucin Altin: supervision and writing—review and editing. Omer Akyurek: supervision and formal analysis. Busra Kuru: data collection. Kubra Korkmaz: data collection. Ibrahim Ersoy: writing—original draft. Volkan Kozluca and Irem Muge Akbulut: formal analysis. Eralp Tutar: supervision.
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Supplementary informations
Supplemental Video. At the first propagation left atrium activation is pseudo-focal starting at the left atrial appendage ridge (endocardial breakthrough). Activation is slow and short in clockwise direction; however, it proceeds in counterclockwise direction until mitral annulus 5 o’clock, upon which there is no endocardial activation. Again, activation re-appears at endocardial breakthrough site. This activation pattern can be explained by Vein of Marshall bypass tract. In the second part, atrial tachycardia presumably utilizing septopulmonary bundle is depicted. Endocardial breakthrough occurs at the inferior border of a putative septopulmonary bundle. Activation proceeds in a pseudo-focal nature. Septopulmonary bundle engagement probably occurs when endocardial activation reaches posterior roof of right upper pulmonary vein. Finally, in the third propagation video, endocardial breakthrough site is at the Bachmann’s bundle endocardial neighborhood. Left atrium activates in a pseudo-focal fashion. After the atrium has been activated, activation reappears at the endocardial breakthrough site. Bachmann’s bundle epicardial bypass may explain the missing re-entrant circuit part.
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Baskovski, E., Altin, A.T., Akyurek, O. et al. Electrophysiological characteristics of epicardial atrial tachycardias and endocardial breakthrough site targeting for ablation: a single center experience. J Interv Card Electrophysiol 66, 1901–1910 (2023). https://doi.org/10.1007/s10840-023-01513-z
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DOI: https://doi.org/10.1007/s10840-023-01513-z