Counter-clockwise Isthmus-Dependent Peritricuspid Reentry with an Atypical Electrocardiographic Pattern: what Should Be Complex is not Always Actually Complex


This is a 79-year-old-female patient with hypertensive heart disease without previous cardiac or thoracic surgery. Two years before the procedure described here, she presented with recurrent episodes of atrial fibrillation, which was treated with oral amiodarone at a dose of 1.4 g per week. An echocardiogram in sinus rhythm showed a hypertrophic left ventricle with impaired systolic function (ejection fraction of 44%), enlargement of both atria and moderate mitral and tricuspid regurgitation. On antiarrhytmic therapy, she had no recurrence of atrial fibrillation, but six months before the procedure she exhibited recurrent episodes of persistent atypical atrial flutter. These were poorly tolerated and required electrical cardioversion for their termination. As shown in Fig. 1, surface P wave morphology during the clinical arrhythmia was positive
Figure 1.

Twelve-lead electrocardiogram of the clinical arrhythmia with a 250 ms cycle length and variable atrioventricular conduction.

in the inferior leads and in all precordial leads, flat in I and negative in aVL, suggesting a left atrial arrhythmia. The procedure described below was performed during hospitalisation for arrhythmia recurrence.


Hypertensive Heart Disease Tricuspid Annulus Left Anterior Oblique Inferior Lead Coronary Sinus Ostium 
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© Springer-Verlag Italia 2008

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