Angiographic Anatomy of the Inferior Right Atrial Isthmus in Patients With and Without History of Common Atrial Flutter

Cabrera, José Ángel; Sánchez‐Quintana, Damian; Ho, Siew Yen; Medina, Alfonso; Wangüemert, Fernando; Groß, E.; Grillo, José J.; Hernández, Enrique; Anderson, Robert H.

doi:10.1161/01.cir.99.23.3017

Cited by 117 publications

(115 citation statements)

References 18 publications

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“…An isthmogram was performed by positioning a 5F pigtail catheter in the IVC just at the level of the splenic and hepatic veins. 9,10 Contrast solution was injected during 3 to 5 seconds for a total of 50 cm 3 in each patient. The angiograms were digitally acquired, thus allowing replay and storage of right anterior oblique (RAO) frames as reference during the subsequent ablation.…”

Section: Right Atrial Angiographymentioning

confidence: 99%

“…14,23 Impact of Right Atrial Length and Anatomy for AFL RFA Previous anatomic and angiographic reports studying human hearts have pointed to the anatomic variability of the isthmus, reporting an average width of 27Ϯ3.3 to 37Ϯ8 mm and different morphologies. 9,10,24 In a landmark study, the authors revealed a highly variable isthmus anatomy and its impact to adjust the ablation tactic. 10 The presence of a eustachian valve or concave isthmus was associated with statistically more RF applications, and the same trend was seen for patients with deep pouches.…”

Section: Comparison Between 8-mm-tip and Cooled-tip Cathetersmentioning

confidence: 99%

“…Recent right atrial angiographic studies have demonstrated a highly variable isthmus anatomy with various configurations and topologies. 9,10 These anatomic aspects seem to lead to more difficult ablation sessions 10 : one study correlated 100 isthmus anatomies with number of applications and reached significance (Pϭ0.05 exactly), correlating median RF applications to concave isthmi. A smaller study with 40 patients reported a linear relationship between isthmus length and number of applications.…”

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confidence: 99%

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Effect of Isthmus Anatomy and Ablation Catheter on Radiofrequency Catheter Ablation of the Cavotricuspid Isthmus

Costa¹,

Faure²,

Thévénin³

et al. 2004

Circulation

112

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Background-Cavotricuspid isthmus (CTI) characteristics are rarely documented when comparing catheters in radiofrequency ablation (RFA) of atrial flutter (AFL). Our objectives were (1) to evaluate the impact of CTI morphology and length on ablation procedures and (2) to compare the efficacy of an 8-mm-tip catheter with an irrigated cooled-tip RFA in the subgroup presumed to be more difficult to treat (with a long CTI, Ͼ35 mm). Methods and Results-Over a period of 17 months, 185 patients accepted the protocol and underwent an isthmogram in preparation for RFA. Groups were classified according to CTI length and CTI morphology. RFA was performed with an 8-mm-tip catheter for patients with a short CTI, Յ35 mm (nϭ123), whereas randomization between an 8-mm-tip and a cooled-tip catheter applied to patients with a longer CTI, Ͼ35 mm (nϭ62). For long CTI, 32 patients were assigned to an 8-mm catheter and 30 patients to the cooled-tip RFA ablation group. In this subset, RF application (18.2Ϯ17 versus 19Ϯ13 minutes) and x-ray exposure (20.8Ϯ18 versus 18Ϯ13 minutes) did not differ between the 8-mm-tip and the cooled-tip procedures. Number of applications (9.9Ϯ11 versus 18.6Ϯ15 minutes; PϽ0.0001) and x-ray exposure (11.7Ϯ11 versus 19.5Ϯ16 minutes, Pϭ0.0001) differed significantly between patients with short and long CTIs.Patients with short and straight CTIs required 3 times fewer RFA applications and shorter x-ray exposure compared with other CTI morphologies (pouch-like recesses and concave characteristics). Conclusions-The number of RF applications required for a complete isthmus block in long CTIs is not influenced by the choice between an 8-mm or cooled-tip catheter. Procedure parameters, however, are significantly influenced by CTI length and morphology. Pouch-like recesses and concave characteristics account for much longer ablation times at all

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Section: Right Atrial Angiographymentioning

confidence: 99%

Section: Comparison Between 8-mm-tip and Cooled-tip Cathetersmentioning

confidence: 99%

mentioning

confidence: 99%

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Effect of Isthmus Anatomy and Ablation Catheter on Radiofrequency Catheter Ablation of the Cavotricuspid Isthmus

Costa¹,

Faure²,

Thévénin³

et al. 2004

Circulation

112

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“…The width of the isthmus in the RAO view was measured between the IVC and the lower hinge point of the tricuspid valve (points A and B in Figure 1A). The isthmus often could be divided into a recess (inferoposterior to the CS ostium) and a flat vestibule (between this recess and the TA) 11 : The width of each was measured. The perpendicular distance between the line connecting A and B and the deepest point of the isthmus was quantified.…”

Section: Ra Angiographymentioning

confidence: 99%

“…Right atrial angiography is a widely available and inexpensive alternative. 11 We postulated that visualizing the anatomic conformation of the isthmus could rationalize the ablation approach.…”

mentioning

confidence: 99%

Right Atrial Angiographic Evaluation of the Posterior Isthmus

et al. 2000

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Background-Gaining anatomic information about the posterior isthmus is not generally part of flutter ablation procedures. We postulated that right atrial (RA) angiography could rationalize the ablation approach by revealing the conformation of the isthmus. Methods and Results-In 100 consecutive patients, biplane RA angiography was performed before ablation to guide catheter contact with the isthmus along its length. Angiography showed a wide variation in the width of the isthmus (17 to 54 mm; 31.3Ϯ7.9), its angle with the inferior vena cava in the right anterior oblique projection (68°to 114°; 90.3Ϯ9.0°), and its lateral position relative to the inferior vena cava in the left anterior oblique projection. A deep sub-Eustachian recess was revealed in 47%, with a mean depth of 4.3Ϯ2.1 mm (1.5 to 9.4). A Eustachian valve was visualized in 24%. Ablation resulted in bidirectional conduction block (which could be transient) in all, with a median of 2 dragging radiofrequency (RF) applications (2.3Ϯ2.5 RF applications; 57°C, Յ99 seconds each). Permanent block was achieved in 99%, with a median of 3 RF applications (3.4Ϯ3.0). The presence of a Eustachian valve or concave isthmus was associated with statistically more RF applications; the same trend was seen for patients with deep pouches. The number of RF applications decreased statistically throughout the study, indicating a learning curve. No patient had a recurrence after a follow-up of 13Ϯ11 months. Conclusions-Right atrial angiography reveals a highly variable isthmus anatomy, often showing particular configurations that can make ablation more laborious. Rational adaptation of the ablation approach to these anatomic findings may contribute to successful ablation.

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Overview of Cardiac Anatomy Relevant to Catheter Ablation

Ho¹

2007

Catheter Ablation of Cardiac Arrhythmias

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Angiographic Anatomy of the Inferior Right Atrial Isthmus in Patients With and Without History of Common Atrial Flutter

Abstract: The inferior isthmus and right atrium in patients with common atrial flutter were significantly larger than those in a control population.

Cited by 117 publications

References 18 publications

Effect of Isthmus Anatomy and Ablation Catheter on Radiofrequency Catheter Ablation of the Cavotricuspid Isthmus

Effect of Isthmus Anatomy and Ablation Catheter on Radiofrequency Catheter Ablation of the Cavotricuspid Isthmus

Right Atrial Angiographic Evaluation of the Posterior Isthmus

Overview of Cardiac Anatomy Relevant to Catheter Ablation

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