Fayez Bokhari a,⇑, Moayad AlQurashi a, Omar Raslan a, Nabil Alama a a
Cardiology Department, King Fahd Armed Forces Hospital, Jeddah
a
Saudi Arabia
We report the case of a 40-year-old patient with incessant supraventricular tachycardia (SVT). As this SVT was resistant to medical therapy and was complicated by severe LV dysfunction and cardiogenic shock, the patient was referred for EPS (electrophysiologic study) and ablation. EPS and successful ablation of the right atrial appendage (RAA) tachycardia were performed by means of a 3D mapping system NavX (St. Jude Medical, St. Paul, MN, USA) with complete resolution of symptoms and normalization of LV function, as evaluated at three-month follow-up examination. Ó 2013 Production and hosting by Elsevier B.V. on behalf of King Saud University. Keywords: Atrial tachycardia, Right atrial appendage, 3 Dimensional mapping, Catheter ablation, Tachycardia induced cardiomyopathy
Introduction
F
ocal atrial tachycardias (AT) tend to originate from specific anatomic locations in the atria. The right atrial appendage (RAA) is defined as the pectinate anterior region of the right atrium, extending from the posterior of the crista terminalis to the anterior of the triangulated component [1]. Previous studies [2–6] have identified the RAA as a rare site of focal AT, the commonest site being
the crista terminalis. Other possible sites include the coronary sinus ostium, tricuspid annulus and interatrial septum. Radiofrequency ablation is difficult in the RAA region owing to the difficulty of achieving adequate power and maneuvering the catheter in this complex trabeculated region. Surgical excision [7] is used to treat ectopic AT in the rare cases when this condition is associated with RAA aneurysm. Data on the radiofrequency ablation of RAA tachycardia by means of a non-irrigated ablation catheter guided by a 3D
Disclosure: Authors have nothing to disclose with regard to commercial support. Received 22 February 2013; revised 11 April 2013; accepted 20 April 2013. Available online 7 May 2013
⇑ Corresponding author. Address: King Fahd Armed Forces Hospital, P.O. Box 9862, Jeddah 21159, Saudi Arabia. Tel.: +966 535663111; fax: +966 26651868. E-mail address: [email protected] (F. Bokhari).
P.O. Box 2925 Riyadh – 11461KSA Tel: +966 1 2520088 ext 40151 Fax: +966 1 2520718 Email: [email protected] URL: www.sha.org.sa
1016–7315 Ó 2013 Production and hosting by Elsevier B.V. on behalf of King Saud University. Peer review under responsibility of King Saud University. URL: www.ksu.edu.sa http://dx.doi.org/10.1016/j.jsha.2013.04.002
Production and hosting by Elsevier
CASE REPORT
Right atrial appendage tachycardia: A rare cause of tachycardia induced cardiomyopathy with successful radiofrequency ablation using the 3D mapping system
266
BOKHARI ET AL RIGHT ATRIAL APPENDAGE TACHYCARDIA: A RARE CAUSE OF TACHYCARDIA INDUCED CARDIOMYOPATHY WITH SUCCESSFUL RADIOFREQUENCY ABLATION USING THE 3D MAPPING SYSTEM
CASE REPORT
mapping system are limited. Here, we report one such case.
Case report This 40-year-old female patient had a 10-yearhistory of recurrent palpitations and shortness of breath. One such episode, which had lasted for a few weeks, resulted in her being admitted to another hospital, where she was diagnosed as having heart failure and refractory SVT (Fig. 1). She first received IV verapamil (5 mg), which only slowed the tachycardia (Fig. 2), then IV digoxin, B-
J Saudi Heart Assoc 2013;25:265–271
blocker, Calcium channel blocker, amiodarone and finally DC shock. Tachycardia was terminated by the DC shock but immediately recurred. The patient’s hospital stay was complicated by cardiogenic shock requiring brief intubation, diuresis and inotropic therapy. She was referred to us for an electrophysiologic study and SVT ablation. On admission, the patient was conscious and oriented; her heart rate was 180 bpm, blood pressure 95/70 mmHg, respiratory rate 18 breaths per minute, oxygen saturation 99% on 2 L nasal oxygen cannula and her body temperature was 36.6 °C. Physical examination showed mild heart failure.
Figure 1. 12-Lead surface ECG showing SVT consistent with atrial tachycardia originating in the RA appendage with the characteristic negative P wave in lead V1.
Figure 2. 12-Lead surface ECG following 5 mg IV verapamil, showing slowing of atrial tachycardia with transient 2:1 AV block.
J Saudi Heart Assoc 2013;25:265–271
267
CASE REPORT
BOKHARI ET AL RIGHT ATRIAL APPENDAGE TACHYCARDIA: A RARE CAUSE OF TACHYCARDIA INDUCED CARDIOMYOPATHY WITH SUCCESSFUL RADIOFREQUENCY ABLATION USING THE 3D MAPPING SYSTEM
Figure 3. Intracardiac electrograms and surface ECG during EPS at King Fahd Armed Forces Hospital showing incessant SVT. The earliest activation was in the anterolateral area of the RA (RA7–8) near the RA appendage. The Duodeca halo RA catheter is placed in the lateral wall of the RA. Other catheters are placed in the His region, Coronary Sinus and RV apex.
1
1
3
3 3
4 4
2 2
Figure 4. 3D mapping and ablation of RA appendage tachycardia using NavX system (St. Jude Medical, St. Paul, MN, USA). Isochronal activation map constructed during tachycardia using proximal CS atrial signal as a reference. The color coded display of the activation time in the right atrium measured relative to the reference point with red being early and blue being late. Activation map shows a very early target (red) in the right atrial appendage area. Successful ablation sites are colored brown (transient success) and yellow (permanent success). Catheters labeled as follows: (1) ablation, (2) halo, (3) coronary sinus, (4) His catheters.
268
BOKHARI ET AL RIGHT ATRIAL APPENDAGE TACHYCARDIA: A RARE CAUSE OF TACHYCARDIA INDUCED CARDIOMYOPATHY WITH SUCCESSFUL RADIOFREQUENCY ABLATION USING THE 3D MAPPING SYSTEM
J Saudi Heart Assoc 2013;25:265–271
CASE REPORT
all heart chambers. The provisional differential diagnosis on admission was tachycardia-induced cardiomyopathy vs. non-ischemic dilated cardiomyopathy. 1 4
5
Procedure 2
3
1
4 5 2 3
Figure 5. Chest X-ray in the RAO (top) and LAO (bottom) views showing the 4 mm tip ablation catheter (1) at the successful ablation site deep inside the triangulated anterior right atrial appendage. Other catheters seen in the RV (2), the Duodeca halo catheter in the lateral wall of the RA (3), Coronary Sinus (4) and His region (5).
All blood test values were within normal ranges, including those related to thyroid functions. ECG (Fig. 1) showed narrow complex regular tachycardia at 180 bpm with large monophasic negative P waves in V1 and positive P waves in the other front leads. Transthoracic echocardiography showed an ejection fraction of 20%, with global severely impaired left ventricular function, normal pulmonary artery pressure and normal sizes of
Informed consent was obtained and all risks were explained to the patient in detail. EPS and ablation were performed by means of catheters positioned in the RA, RV and His region; a Halo catheter was positioned parallel to the crista terminalis, which was accessed through the right femoral vein, while the catheter positioned in the coronary sinus was inserted through the right internal jugular vein. At the baseline, the patient was in incessant SVT (Fig. 3) with characteristic large negative P waves in V1. Occasionally, she had transient 2:1, 3:1 AV block with continuation of atrial tachycardia. The NavX system (St. Jude Medical, St. Paul, MN, USA) was used to perform 3D mapping and to construct right atrial geometry. The superior vena cava, inferior vena cava, coronary sinus, His region, interatrial septum and tricuspid annulus were tagged and labeled. Catheter manipulations inside the RAA terminated tachycardia, which, however, immediately recurred. Activation mapping was performed during tachycardia by using the ablation catheter as a rover and the proximal CS atrial signal as a reference. The activation map showed a very early target in and around the RAA (Fig. 4). Mapping of the region was performed carefully and gently in order to reduce the risk of perforation by the catheter tip. Radiofrequency ablation was performed at early sites (using a 4 mm, non-irrigated deflectable-tip Thermistor, Biosense Webster, CA, USA) just outside the triangulated atrial appendage, though without success. Radiofrequency ablation was then performed in the triangulated anterior portion of the RAA (Figs. 4 and 5) at low levels of both temperature (40 °C) and power (40 W). This achieved transient success. Subsequent brief (20 s) radiofrequency ablation at a higher temperature (60 °C) and higher power (50 W) in the same area finally achieved permanent success and terminated the tachycardia after 13 s (Fig. 6). The successful target in this location showed very early activation before the beginning of the P wave on the surface ECG (Fig. 7). Post-ablation electrophysiology study showed AV node Wenckebach cycle length of 340 ms, AV node effective refractory period of 400/340 ms and no evidence of VA conduction. The patient tolerated the procedure
BOKHARI ET AL RIGHT ATRIAL APPENDAGE TACHYCARDIA: A RARE CAUSE OF TACHYCARDIA INDUCED CARDIOMYOPATHY WITH SUCCESSFUL RADIOFREQUENCY ABLATION USING THE 3D MAPPING SYSTEM
269
CASE REPORT
J Saudi Heart Assoc 2013;25:265–271
Figure 6. Intracardiac electrograms and surface ECG during ablation at the successful site inside RA appendage showing successful termination of tachycardia after 13.4 s. The Duodeca halo RA catheter is placed in the lateral wall of the RA. Other catheters are placed in the His region, Coronary Sinus and RV apex.
Figure 7. Intracardiac electrograms and surface ECG during ablation at the successful site inside the RA appendage showing the successful target pre P wave on the surface ECG just before successful termination. The Duodeca halo RA catheter is placed in the lateral wall of the RA. Other catheters are placed in the His region, Coronary Sinus and RV apex.
270
BOKHARI ET AL RIGHT ATRIAL APPENDAGE TACHYCARDIA: A RARE CAUSE OF TACHYCARDIA INDUCED CARDIOMYOPATHY WITH SUCCESSFUL RADIOFREQUENCY ABLATION USING THE 3D MAPPING SYSTEM
J Saudi Heart Assoc 2013;25:265–271
CASE REPORT Figure 8. Post-ablation 12-lead surface ECG showing sinus rhythm.
well. After ablation, the patient remained in sinus rhythm with no inducible or spontaneous tachycardia, whether on or off IV Isuprel infusion (Fig. 8). Cardiac MRI ruled out atrial appendage aneurysm. The patient was discharged home only on beta-blocker therapy for LV dysfunction. During 3 months of post-ablation follow-up, she suffered no AT recurrences and a repeat echocardiography showed normal LV function.
Discussion This case is important because RAA is a rare site for focal AT, radiofrequency ablation is difficult in the RAA, and finally because data about radiofrequency ablation of RAA tachycardia using nonirrigated ablation catheter guided by a 3D mapping system are limited.
angulated portion of the right atrium to treat atrial tachycardias whose earliest activation site was in the RAA. Patients in that study were mostly young (32 ± 14 years), had heart rates of 157 ± 24 bpm, incessant AT and severe symptoms.
Identification of RAA tachycardia ECG plays an integral role in identifying and differentiating RAA tachycardia from other atrial tachycardias. RAA tachycardias display specific electrocardiographic features, such as a negative P wave in lead V1 and a positive P wave in lead 1 and the inferior leads, as shown in our case report and several previous studies. [8–12].
Take home messages
The main findings of this case report are that: (1) we mapped the earliest AT activation point inside the RAA; (2) we successfully ablated the AT inside the RAA, and (3) the patient had no AT recurrence and her LV function was normalized, which confirms the diagnosis of tachycardia-induced cardiomyopathy.
This case report presented clinically valuable lessons particularly in differential diagnosis, tachycardia-induced cardiomyopathy vs. nonischemic dilated cardiomyopathy, as well as in the diagnostic challenge of identifying the AT focal site and the difficulty of radiofrequency ablation in the RAA. As the tip of the catheter is rigid, mapping in this region requires gentle manipulation and ablation must be carried out carefully at the lowest possible power and temperature in order to avoid perforation.
Previous reports
References
Main results
The literature contains few case reports of atrial tachycardia originating from the right atrial appendage [8–12]. Our patient displayed similar clinical features to those seen in the case series of RAA tachycardia reported by Freixa et al. [8], who performed successful ablation inside the tri-
[1] Anderson RH, Razavi R, Taylor AM. Cardiac anatomy revisited. J Anat 2004;205(3):159–77. [2] Roberts-Thomson KC, Kistler PM, Haqqani HM, et al. Focal atrial tachycardias arising from the right atrial appendage: electrocardiographic and electrophysiologic characteristics and radiofrequency ablation. J Cardiovasc Electrophysiol 2007;18(4):367–72.
BOKHARI ET AL RIGHT ATRIAL APPENDAGE TACHYCARDIA: A RARE CAUSE OF TACHYCARDIA INDUCED CARDIOMYOPATHY WITH SUCCESSFUL RADIOFREQUENCY ABLATION USING THE 3D MAPPING SYSTEM
[3] Kalman JM, Olgin JE, Karch MR, Hamdan M, Lee RJ, Lesh MD. ‘‘Cristal tachycardias’’: origin of right atrial tachycardias from the crista terminalis identified by intracardiac echocardiography. J Am Coll Cardiol 1998;31(2):451–9. [4] Kistler PM, Fynn SP, Haqqani H, et al. Focal atrial tachycardia from the ostium of the coronary sinus: electrocardiographic and electrophysiological characterization and radiofrequency ablation. J Am Coll Cardiol 2005;45(9):1488–93. [5] Morton JB, Sanders P, Das A, Vohra JK, Sparks PB, Kalman JM. Focal atrial tachycardia arising from the tricuspid annulus: electrophysiologic and electrocardiographic characteristics. J Cardiovasc Electrophysiol 2001;12(6):653–9. [6] Chen CC, Tai CT, Chiang C, et al. Atrial tachycardias originating from the atrial septum: electrophysiologic characteristics and radiofrequency ablation. J Cardiovasc Electrophysiol 2000;11(7):744–9. [7] Mizui S, Mori K, Kuroda Y. Ectopic atrial tachycardia due to aneurysm of the right atrial appendage. Cardiol Young 2001;11(2):229–32.
271
[8] Freixa X, Berruezo A, Mont L, et al. Characterization of focal right atrial appendage tachycardia. Europace 2008;10(1):105–9. [9] Chun KJ, Ouyang F, Schmidt B, Kuck KH. Focal atrial tachycardia originating from the right atrial appendage: first successful cryoballoon isolation. J Cardiovasc Electrophysiol 2009;20(3):338–41. [10] Furushima H, Chinushi M, Hosaka Y, Aizawa Y. Focal atrial tachycardia refractory to radiofrequency catheter ablation originating from right atrial appendage. Europace 2009;11(4):521–2. [11] Jastrzebski M, Bacior B, Pitak M, Załuska-Pitak B, Rudzin´ski A, Czarnecka D. Focal atrial tachycardia originating in the right atrial appendage. Kardiol Pol 2009;67(12):1412–6. [12] Suenari K, Chang SL, Lin YJ, Lo LW, Chen SA. Unusual ECG pattern of right atrial appendage atrial tachycardia in one patient with right pneumonectomy. Pacing Clin Electrophysiol 2010;33(5):e46–8.
CASE REPORT
J Saudi Heart Assoc 2013;25:265–271
Cardiology Department, King Fahd Armed Forces Hospital, Jeddah
a
Saudi Arabia
We report the case of a 40-year-old patient with incessant supraventricular tachycardia (SVT). As this SVT was resistant to medical therapy and was complicated by severe LV dysfunction and cardiogenic shock, the patient was referred for EPS (electrophysiologic study) and ablation. EPS and successful ablation of the right atrial appendage (RAA) tachycardia were performed by means of a 3D mapping system NavX (St. Jude Medical, St. Paul, MN, USA) with complete resolution of symptoms and normalization of LV function, as evaluated at three-month follow-up examination. Ó 2013 Production and hosting by Elsevier B.V. on behalf of King Saud University. Keywords: Atrial tachycardia, Right atrial appendage, 3 Dimensional mapping, Catheter ablation, Tachycardia induced cardiomyopathy
Introduction
F
ocal atrial tachycardias (AT) tend to originate from specific anatomic locations in the atria. The right atrial appendage (RAA) is defined as the pectinate anterior region of the right atrium, extending from the posterior of the crista terminalis to the anterior of the triangulated component [1]. Previous studies [2–6] have identified the RAA as a rare site of focal AT, the commonest site being
the crista terminalis. Other possible sites include the coronary sinus ostium, tricuspid annulus and interatrial septum. Radiofrequency ablation is difficult in the RAA region owing to the difficulty of achieving adequate power and maneuvering the catheter in this complex trabeculated region. Surgical excision [7] is used to treat ectopic AT in the rare cases when this condition is associated with RAA aneurysm. Data on the radiofrequency ablation of RAA tachycardia by means of a non-irrigated ablation catheter guided by a 3D
Disclosure: Authors have nothing to disclose with regard to commercial support. Received 22 February 2013; revised 11 April 2013; accepted 20 April 2013. Available online 7 May 2013
⇑ Corresponding author. Address: King Fahd Armed Forces Hospital, P.O. Box 9862, Jeddah 21159, Saudi Arabia. Tel.: +966 535663111; fax: +966 26651868. E-mail address: [email protected] (F. Bokhari).
P.O. Box 2925 Riyadh – 11461KSA Tel: +966 1 2520088 ext 40151 Fax: +966 1 2520718 Email: [email protected] URL: www.sha.org.sa
1016–7315 Ó 2013 Production and hosting by Elsevier B.V. on behalf of King Saud University. Peer review under responsibility of King Saud University. URL: www.ksu.edu.sa http://dx.doi.org/10.1016/j.jsha.2013.04.002
Production and hosting by Elsevier
CASE REPORT
Right atrial appendage tachycardia: A rare cause of tachycardia induced cardiomyopathy with successful radiofrequency ablation using the 3D mapping system
266
BOKHARI ET AL RIGHT ATRIAL APPENDAGE TACHYCARDIA: A RARE CAUSE OF TACHYCARDIA INDUCED CARDIOMYOPATHY WITH SUCCESSFUL RADIOFREQUENCY ABLATION USING THE 3D MAPPING SYSTEM
CASE REPORT
mapping system are limited. Here, we report one such case.
Case report This 40-year-old female patient had a 10-yearhistory of recurrent palpitations and shortness of breath. One such episode, which had lasted for a few weeks, resulted in her being admitted to another hospital, where she was diagnosed as having heart failure and refractory SVT (Fig. 1). She first received IV verapamil (5 mg), which only slowed the tachycardia (Fig. 2), then IV digoxin, B-
J Saudi Heart Assoc 2013;25:265–271
blocker, Calcium channel blocker, amiodarone and finally DC shock. Tachycardia was terminated by the DC shock but immediately recurred. The patient’s hospital stay was complicated by cardiogenic shock requiring brief intubation, diuresis and inotropic therapy. She was referred to us for an electrophysiologic study and SVT ablation. On admission, the patient was conscious and oriented; her heart rate was 180 bpm, blood pressure 95/70 mmHg, respiratory rate 18 breaths per minute, oxygen saturation 99% on 2 L nasal oxygen cannula and her body temperature was 36.6 °C. Physical examination showed mild heart failure.
Figure 1. 12-Lead surface ECG showing SVT consistent with atrial tachycardia originating in the RA appendage with the characteristic negative P wave in lead V1.
Figure 2. 12-Lead surface ECG following 5 mg IV verapamil, showing slowing of atrial tachycardia with transient 2:1 AV block.
J Saudi Heart Assoc 2013;25:265–271
267
CASE REPORT
BOKHARI ET AL RIGHT ATRIAL APPENDAGE TACHYCARDIA: A RARE CAUSE OF TACHYCARDIA INDUCED CARDIOMYOPATHY WITH SUCCESSFUL RADIOFREQUENCY ABLATION USING THE 3D MAPPING SYSTEM
Figure 3. Intracardiac electrograms and surface ECG during EPS at King Fahd Armed Forces Hospital showing incessant SVT. The earliest activation was in the anterolateral area of the RA (RA7–8) near the RA appendage. The Duodeca halo RA catheter is placed in the lateral wall of the RA. Other catheters are placed in the His region, Coronary Sinus and RV apex.
1
1
3
3 3
4 4
2 2
Figure 4. 3D mapping and ablation of RA appendage tachycardia using NavX system (St. Jude Medical, St. Paul, MN, USA). Isochronal activation map constructed during tachycardia using proximal CS atrial signal as a reference. The color coded display of the activation time in the right atrium measured relative to the reference point with red being early and blue being late. Activation map shows a very early target (red) in the right atrial appendage area. Successful ablation sites are colored brown (transient success) and yellow (permanent success). Catheters labeled as follows: (1) ablation, (2) halo, (3) coronary sinus, (4) His catheters.
268
BOKHARI ET AL RIGHT ATRIAL APPENDAGE TACHYCARDIA: A RARE CAUSE OF TACHYCARDIA INDUCED CARDIOMYOPATHY WITH SUCCESSFUL RADIOFREQUENCY ABLATION USING THE 3D MAPPING SYSTEM
J Saudi Heart Assoc 2013;25:265–271
CASE REPORT
all heart chambers. The provisional differential diagnosis on admission was tachycardia-induced cardiomyopathy vs. non-ischemic dilated cardiomyopathy. 1 4
5
Procedure 2
3
1
4 5 2 3
Figure 5. Chest X-ray in the RAO (top) and LAO (bottom) views showing the 4 mm tip ablation catheter (1) at the successful ablation site deep inside the triangulated anterior right atrial appendage. Other catheters seen in the RV (2), the Duodeca halo catheter in the lateral wall of the RA (3), Coronary Sinus (4) and His region (5).
All blood test values were within normal ranges, including those related to thyroid functions. ECG (Fig. 1) showed narrow complex regular tachycardia at 180 bpm with large monophasic negative P waves in V1 and positive P waves in the other front leads. Transthoracic echocardiography showed an ejection fraction of 20%, with global severely impaired left ventricular function, normal pulmonary artery pressure and normal sizes of
Informed consent was obtained and all risks were explained to the patient in detail. EPS and ablation were performed by means of catheters positioned in the RA, RV and His region; a Halo catheter was positioned parallel to the crista terminalis, which was accessed through the right femoral vein, while the catheter positioned in the coronary sinus was inserted through the right internal jugular vein. At the baseline, the patient was in incessant SVT (Fig. 3) with characteristic large negative P waves in V1. Occasionally, she had transient 2:1, 3:1 AV block with continuation of atrial tachycardia. The NavX system (St. Jude Medical, St. Paul, MN, USA) was used to perform 3D mapping and to construct right atrial geometry. The superior vena cava, inferior vena cava, coronary sinus, His region, interatrial septum and tricuspid annulus were tagged and labeled. Catheter manipulations inside the RAA terminated tachycardia, which, however, immediately recurred. Activation mapping was performed during tachycardia by using the ablation catheter as a rover and the proximal CS atrial signal as a reference. The activation map showed a very early target in and around the RAA (Fig. 4). Mapping of the region was performed carefully and gently in order to reduce the risk of perforation by the catheter tip. Radiofrequency ablation was performed at early sites (using a 4 mm, non-irrigated deflectable-tip Thermistor, Biosense Webster, CA, USA) just outside the triangulated atrial appendage, though without success. Radiofrequency ablation was then performed in the triangulated anterior portion of the RAA (Figs. 4 and 5) at low levels of both temperature (40 °C) and power (40 W). This achieved transient success. Subsequent brief (20 s) radiofrequency ablation at a higher temperature (60 °C) and higher power (50 W) in the same area finally achieved permanent success and terminated the tachycardia after 13 s (Fig. 6). The successful target in this location showed very early activation before the beginning of the P wave on the surface ECG (Fig. 7). Post-ablation electrophysiology study showed AV node Wenckebach cycle length of 340 ms, AV node effective refractory period of 400/340 ms and no evidence of VA conduction. The patient tolerated the procedure
BOKHARI ET AL RIGHT ATRIAL APPENDAGE TACHYCARDIA: A RARE CAUSE OF TACHYCARDIA INDUCED CARDIOMYOPATHY WITH SUCCESSFUL RADIOFREQUENCY ABLATION USING THE 3D MAPPING SYSTEM
269
CASE REPORT
J Saudi Heart Assoc 2013;25:265–271
Figure 6. Intracardiac electrograms and surface ECG during ablation at the successful site inside RA appendage showing successful termination of tachycardia after 13.4 s. The Duodeca halo RA catheter is placed in the lateral wall of the RA. Other catheters are placed in the His region, Coronary Sinus and RV apex.
Figure 7. Intracardiac electrograms and surface ECG during ablation at the successful site inside the RA appendage showing the successful target pre P wave on the surface ECG just before successful termination. The Duodeca halo RA catheter is placed in the lateral wall of the RA. Other catheters are placed in the His region, Coronary Sinus and RV apex.
270
BOKHARI ET AL RIGHT ATRIAL APPENDAGE TACHYCARDIA: A RARE CAUSE OF TACHYCARDIA INDUCED CARDIOMYOPATHY WITH SUCCESSFUL RADIOFREQUENCY ABLATION USING THE 3D MAPPING SYSTEM
J Saudi Heart Assoc 2013;25:265–271
CASE REPORT Figure 8. Post-ablation 12-lead surface ECG showing sinus rhythm.
well. After ablation, the patient remained in sinus rhythm with no inducible or spontaneous tachycardia, whether on or off IV Isuprel infusion (Fig. 8). Cardiac MRI ruled out atrial appendage aneurysm. The patient was discharged home only on beta-blocker therapy for LV dysfunction. During 3 months of post-ablation follow-up, she suffered no AT recurrences and a repeat echocardiography showed normal LV function.
Discussion This case is important because RAA is a rare site for focal AT, radiofrequency ablation is difficult in the RAA, and finally because data about radiofrequency ablation of RAA tachycardia using nonirrigated ablation catheter guided by a 3D mapping system are limited.
angulated portion of the right atrium to treat atrial tachycardias whose earliest activation site was in the RAA. Patients in that study were mostly young (32 ± 14 years), had heart rates of 157 ± 24 bpm, incessant AT and severe symptoms.
Identification of RAA tachycardia ECG plays an integral role in identifying and differentiating RAA tachycardia from other atrial tachycardias. RAA tachycardias display specific electrocardiographic features, such as a negative P wave in lead V1 and a positive P wave in lead 1 and the inferior leads, as shown in our case report and several previous studies. [8–12].
Take home messages
The main findings of this case report are that: (1) we mapped the earliest AT activation point inside the RAA; (2) we successfully ablated the AT inside the RAA, and (3) the patient had no AT recurrence and her LV function was normalized, which confirms the diagnosis of tachycardia-induced cardiomyopathy.
This case report presented clinically valuable lessons particularly in differential diagnosis, tachycardia-induced cardiomyopathy vs. nonischemic dilated cardiomyopathy, as well as in the diagnostic challenge of identifying the AT focal site and the difficulty of radiofrequency ablation in the RAA. As the tip of the catheter is rigid, mapping in this region requires gentle manipulation and ablation must be carried out carefully at the lowest possible power and temperature in order to avoid perforation.
Previous reports
References
Main results
The literature contains few case reports of atrial tachycardia originating from the right atrial appendage [8–12]. Our patient displayed similar clinical features to those seen in the case series of RAA tachycardia reported by Freixa et al. [8], who performed successful ablation inside the tri-
[1] Anderson RH, Razavi R, Taylor AM. Cardiac anatomy revisited. J Anat 2004;205(3):159–77. [2] Roberts-Thomson KC, Kistler PM, Haqqani HM, et al. Focal atrial tachycardias arising from the right atrial appendage: electrocardiographic and electrophysiologic characteristics and radiofrequency ablation. J Cardiovasc Electrophysiol 2007;18(4):367–72.
BOKHARI ET AL RIGHT ATRIAL APPENDAGE TACHYCARDIA: A RARE CAUSE OF TACHYCARDIA INDUCED CARDIOMYOPATHY WITH SUCCESSFUL RADIOFREQUENCY ABLATION USING THE 3D MAPPING SYSTEM
[3] Kalman JM, Olgin JE, Karch MR, Hamdan M, Lee RJ, Lesh MD. ‘‘Cristal tachycardias’’: origin of right atrial tachycardias from the crista terminalis identified by intracardiac echocardiography. J Am Coll Cardiol 1998;31(2):451–9. [4] Kistler PM, Fynn SP, Haqqani H, et al. Focal atrial tachycardia from the ostium of the coronary sinus: electrocardiographic and electrophysiological characterization and radiofrequency ablation. J Am Coll Cardiol 2005;45(9):1488–93. [5] Morton JB, Sanders P, Das A, Vohra JK, Sparks PB, Kalman JM. Focal atrial tachycardia arising from the tricuspid annulus: electrophysiologic and electrocardiographic characteristics. J Cardiovasc Electrophysiol 2001;12(6):653–9. [6] Chen CC, Tai CT, Chiang C, et al. Atrial tachycardias originating from the atrial septum: electrophysiologic characteristics and radiofrequency ablation. J Cardiovasc Electrophysiol 2000;11(7):744–9. [7] Mizui S, Mori K, Kuroda Y. Ectopic atrial tachycardia due to aneurysm of the right atrial appendage. Cardiol Young 2001;11(2):229–32.
271
[8] Freixa X, Berruezo A, Mont L, et al. Characterization of focal right atrial appendage tachycardia. Europace 2008;10(1):105–9. [9] Chun KJ, Ouyang F, Schmidt B, Kuck KH. Focal atrial tachycardia originating from the right atrial appendage: first successful cryoballoon isolation. J Cardiovasc Electrophysiol 2009;20(3):338–41. [10] Furushima H, Chinushi M, Hosaka Y, Aizawa Y. Focal atrial tachycardia refractory to radiofrequency catheter ablation originating from right atrial appendage. Europace 2009;11(4):521–2. [11] Jastrzebski M, Bacior B, Pitak M, Załuska-Pitak B, Rudzin´ski A, Czarnecka D. Focal atrial tachycardia originating in the right atrial appendage. Kardiol Pol 2009;67(12):1412–6. [12] Suenari K, Chang SL, Lin YJ, Lo LW, Chen SA. Unusual ECG pattern of right atrial appendage atrial tachycardia in one patient with right pneumonectomy. Pacing Clin Electrophysiol 2010;33(5):e46–8.
CASE REPORT
J Saudi Heart Assoc 2013;25:265–271
