Dual-loop circuits in postoperative atrial macro re-entrant tachycardias

Seiler, Jens; Schmid, Dorothy K.; Irtel, Thiemo A.; Tanner, Hildegard; Rotter, Martin; Schwick, Nicola; Delacrétaz, Etienne
March 2007
Heart;Mar2007, Vol. 93 Issue 3, p325
Academic Journal
Background: Patients may develop dual-loop re-entrant atrial arrhythmias late after open-heart surgery, and mapping and catheter ablation remain challenging despite computer-assisted mapping techniques. Objectives: The purpose of the study was to demonstrate the prevalence and characteristics of dual-loop re-entrant arrhythmias, and to define the optimal mapping and ablation strategy. Methods: 40 consecutive patients (mean (SD) age 52 (12) years) with intra-atrial re-entrant tachycardia (IART) after open-heart surgery (with an incision of the right atrial free wall) were studied. Dual-loop IART was defined as the presence of two simultaneous atrial circuits. After an abrupt tachycardia change during radiofrequency ablation, electrical disconnection of the targeted re-entry isthmus from the remaining circuit was demonstrated by entrainment mapping. Furthermore, the second circuit loop was localised using electroanatomical mapping and/or entrainment mapping. Results: Dual-loop IART was demonstrated in eight (20%, 5 patients with congenital heart disease, 3 with acquired heart disease) patients. Dual-loop IART included an isthmus-dependant atrial flutter combined with a re-entry related to the atriotomy scar. The diagnosis of dual-loop IART required the comparison of entrainment mapping before and after tachycardia modification. Overall, 35 patients had successful radiofrequency ablation (88%). Success rates were lower in patients with dual-loop ART than in patients without dual-loop IART. Ablation failures in three patients with dual-loop IART were related to the inability to properly transect the second tachycardia isthmus in the right atrial free wall. Conclusions: Dual-loop ART is relatively common after heart surgery involving a right atriotomy. Abrupt tachycardia change and specific entrainment mapping manoeuvres demonstrate these circuits. Electroanatomical mapping appears to be important to assist catheter ablation of periatniotomy circuits.


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