Atrial Macroreentry Involving the Myocardium of the Coronary Sinus: A Unique Mechanism for Atypical Flutter

Olgin, Jeffrey E.; Jayachandran, Jayakrishnan; Engesstein, Erica; Groh, William J.; Zipes, Douglas P.

doi:10.1111/j.1540-8167.1998.tb00886.x

Cited by 108 publications

(81 citation statements)

References 17 publications

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“…21 Multiple disparate con- nections between the right and left atria may allow for the substrate for biatrial flutter, entering the left atrium from the CS, travelling around the pulmonary veins to Bachmann's bundle, reentering the right atrium over this bundle, and travelling down the right atrial septum to link again with the CS, as suggested by Olgin et al 22 …”

Section: Discussionmentioning

confidence: 84%

Use of Electroanatomic Mapping to Delineate Transseptal Atrial Conduction in Humans

et al. 1999

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Background-Interaction between wave fronts in the right and left atrium may be important for maintenance of atrial fibrillation, but little is known about electrophysiological properties and preferential routes of transseptal conduction. Methods and Results-Eighteen patients (age 44Ϯ12 years) without structural heart disease underwent right atrial electroanatomic mapping during pacing from the distal coronary sinus (CS) or the posterior left atrium. During distal CS pacing, 9 patients demonstrated a single transseptal breakthrough near the CS os, 1 patient in the high right atrium near the presumed insertion of Bachmann's bundle and 1 patient near the fossa ovalis. The mean activation time from stimulus to CS os was 48Ϯ15 ms compared with 86Ϯ15 ms to Bachmann's bundle insertion (PϽ0.01) and 59Ϯ23 ms to the fossa ovalis (PϭNS and PϽ0.01, respectively). During left atrial pacing, the earliest right atrial activation was near Bachmann's bundle in 5 and near the fossa ovalis in 4 patients. The activation time from stimulus to CS os was 70Ϯ15 ms compared with 47Ϯ16 ms to Bachmann's bundle (PϽ0.01) and 59Ϯ25 ms to the fossa ovalis (PϭNS). Whereas the total septal activation time was not significantly different during CS pacing compared with left atrial pacing (41Ϯ16 versus 33Ϯ17 ms), the total right atrial activation time was longer during CS pacing (117Ϯ49 versus 79Ϯ15 ms; PϽ0.05). Conclusions-Three distinct sites of early right atrial activation may be demonstrated during left atrial pacing. These sites are in accord with anatomic muscle bundles and may have relevance for maintenance of atrial flutter or fibrillation.

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Section: Discussionmentioning

confidence: 84%

Use of Electroanatomic Mapping to Delineate Transseptal Atrial Conduction in Humans

et al. 1999

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“…[3][4][5][6] Focal atrial tachycardias and focal AF originating in the CS musculature have been reported, [7][8][9][10] and this musculature also contributes to a macroreentrant circuit that generates left atrial flutter.…”

Section: Discussionmentioning

confidence: 99%

A Novel Technique for Improved Lesions in the Coronary Sinus

et al. 2012

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SummaryThe stepwise approach to radiofrequency (RF) ablation of atrial fibrillation (AF) can include ablation of the coronary sinus (CS) by RF delivery at the left atrium (LA) and/or within the CS. In both cases, the energy is applied between the tip electrode of a percutaneous catheter and a dispersive electrode on the body surface. We explored the feasibility of using the electrode rings of a diagnostic catheter placed in the CS as dispersive electrode(s) for RF delivery within the LA and compared this technique to an established CS ablation method.Excised pig hearts were superfused with a pulsatile saline flow. Bipolar ablation was performed between a salineirrigated (20 mL/minute) 4-mm tip electrode placed in the LA adjacent to the CS and 7 electrode rings of a 6F, septapolar, 4-mm nonirrigated electrode placed within the CS adjacent to the LA endocardial electrode. Unipolar ablation was performed between the endocardial electrode and dispersive electrode. A continuous transmural lesion was produced in 6/8 (75%) attempts with bipolar ablation, but in 0/6 (0%) attempts with unipolar ablation. However, the incidence of steam pop tended to be increased with bipolar ablation.Bipolar ablation of the CS appears to be highly effective for creating a transmural LA-CS lesion. ( have been found to generate rapid electrical activity that plays a role in triggering and perpetuating atrial fibrillation (AF).1,2) The coronary sinus (CS) also is covered with a muscle sleeve, and connections, both anatomic and electrical, between this muscle sleeve and the left atrium (LA) have been demonstrated. [3][4][5][6] Focal atrial tachycardias and focal AF originating in the CS musculature have been reported, [7][8][9][10] and this musculature also contributes to a macroreentrant circuit that generates left atrial flutter.11) Moreover, a recent study revealed that double potentials are recorded in the CS more often in patients with paroxysmal AF than in patients without AF, and several studies have suggested that the CS plays a role in triggering and/or maintaining AF that is not terminated by PV isolation. [12][13][14][15] Electrical disconnection by catheter ablation of the CS for either paroxysmal or persistent AF terminates AF persisting after PV isolation in approximately 35% of patients.14) The current approaches to radiofrequency (RF) ablation of the CS include RF delivery within the CS (epicardium) or within the LA (endocardium). In both cases, the energy is applied via a catheter tip electrode. The energy is then dispersed through contact tissue to an indifferent electrode placed on the body surface. We conducted a study in swine hearts to assess the feasibility of using the electrode rings of a catheter placed in CS as dispersive electrode(s) for RF delivery during ablation within the LA and to compare this technique to conventional endocardial LA ablation.

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“…[1][2][3][4][5][6] More recently, attention has been directed to the elucidation and cure of patients with left atrial (LA) circuits. [7][8][9] Olgin et al 9 first described a reentrant circuit involving the musculature of the coronary sinus (CS) that was amenable to ablation of the muscle at the CS ostium. A variety of LA circuits that occurred in patients with organic cardiac disease that were associated with large "silent" areas over the posterior LA have been described.…”

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confidence: 99%

Left Septal Atrial Flutter

et al. 2004

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Background-We describe the clinical and electrophysiological characteristics of a novel macroreentrant form of left atrial flutter circuit. Methods and Results-A total of 11 patients were included in the study. The mean tachycardia cycle length was 278Ϯ41 ms. Nine of the 11 patients were treated with antiarrhythmic drugs at the time of the study for concomitant atrial fibrillation. With the use of entrainment pacing and either the CARTO Biosense mapping system (9 patients) or conventional mapping (2 patients), the flutter circuit was found to rotate around the left septum primum with a critical isthmus located between the pulmonary veins posteriorly and/or mitral annulus anteriorly and the septum primum. In 5 patients, radiofrequency ablation was performed from the septum primum to the right inferior pulmonary vein (group 1), and in 6 patients, a lesion was made from the septum primum to the mitral annulus (group 2). After a follow-up of 13Ϯ6 months, 2 patients in group 1 and all patients in group 2 remained in sinus rhythm without recurrence. Conclusions-Slowing of electric conduction in the left atrial septum due to antiarrhythmic drugs and/or atrial myopathy seems to promote left septal atrial flutter. Radiofrequency ablation of this arrhythmia is usually effective and safe. A line of block between the septum primum and the mitral annulus proved to be effective for cure of tachycardia. (Circulation.

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Atrial Macroreentry Involving the Myocardium of the Coronary Sinus: A Unique Mechanism for Atypical Flutter

Cited by 108 publications

References 17 publications

Use of Electroanatomic Mapping to Delineate Transseptal Atrial Conduction in Humans

Use of Electroanatomic Mapping to Delineate Transseptal Atrial Conduction in Humans

A Novel Technique for Improved Lesions in the Coronary Sinus

Left Septal Atrial Flutter

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