Advertisement

Anatomical characteristics of the cavotricuspid isthmus in patients with and without typical atrial flutter: Analysis with two- and three-dimensional intracardiac echocardiography

  • Yasuo Okumura
  • Ichiro Watanabe
  • Sonoko Ashino
  • Masayoshi Kofune
  • Takeshi Yamada
  • Yasuhiro Takagi
  • Kazunori Kawauchi
  • Kimie Okubo
  • Kenichi Hashimoto
  • Atsushi Shindo
  • Hidezou Sugimura
  • Toshiko Nakai
  • Satoshi Saito
Article

Abstract

Introduction

The cavotricuspid isthmus (CTI) is crucial in the ablation of typical atrial flutter (AFL), and consequently the CTI anatomy and/or its relation to resistant ablation cases have been widely described in human angiographic studies. Intracardiac echocardiography (ICE) has been shown to be a useful tool for determining detailed anatomical information. Thus, this technology may also allow the visualization of the anatomical characteristics of the CTI, providing an opportunity to further understand the anatomy.

Aim

We conducted a study to compare the anatomy of the CTI between the patients with and without AFL and to characterize the anatomy of the CTI in the patients with AFL resistant to ablation.

Materials and methods

Twelve patients with typical AFL and 20 without AFL were enrolled in the study. Two-dimensional (2D) intracardiac echocardiography (ICE) was performed. The recordings were obtained with a 9F, 9-MHz ICE catheter from the right ventricular outflow tract to the inferior vena cava by pulling the catheter back 0.3 mm at a time under guidance with echocardiographic imaging in a respiration-gated manner. Three-dimensional (3D) reconstruction of the images of the CTI were made with a 3D reconstruction system. After the acquisition of the ICE, the CTI ablation was performed in the patients with AFL.

Results

The 2D and 3D images provided clear visualization of the tricuspid valve, coronary sinus ostium, fossa ovalis and Eustachian valve/ridge (EVR). The CTI was significantly longer in the patients with AFL than in those without AFL (median length 24.6 mm (range 17.0–39.1 mm) versus median length 20.6 mm (range 12.5–28.0 mm), respectively, P < 0.05). However, a deep recess due to a prominent EVR was observed in 9 of 12 (75%) patients with AFL and in 12 of 20 (60%) patients without AFL (N.S.). A deep recess and the relatively long CTI were related to aging in all the study patients, and that relationship was similar in a limited number of patients without AFL. In five patients with AFL resistant to ablation, a deep recess and prominent EVR were observed.

Conclusions

The 2D and 3D ICE were useful for visualizing the complex anatomy of the CTI and identifying the anatomical characteristics of the CTIs refractory to ablation therapy. The anatomical changes observed in the CTI region may simply be the result of aging and may partially be involved in the development of AFL.

Keywords

Cavotricuspid isthmus Atrial flutter Catheter ablation Intracardiac echocardiography 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Olshansky, B., Okumura, K., Hess, P. G., & Waldo, A. L. (1990). Demonstration of an area of slow conduction in human atrial flutter. Journal of the American College of Cardiology, 16, 1639–1648.PubMedCrossRefGoogle Scholar
  2. 2.
    Feld, G. K., Fleck, R. P., Chen, P. S., Boyce, K., Bahnson, T. D., Stein, J. B., et al. (1992). Radiofrequency catheter ablation for the treatment of atrial flutter. Identification of a critical zone in the reentrant circuit by endocardial mapping techniques. Circulation, 86, 1233–1240.PubMedGoogle Scholar
  3. 3.
    Cosio, F. G., Lopez-Gil, M., Goicolea, A., Arribas, F., & Barroso, J. L. (1993). Radiofrequency ablation of the inferior vena cava-tricuspid valve isthmus in common atrial flutter. American Journal of Cardiology, 71, 705–709.PubMedCrossRefGoogle Scholar
  4. 4.
    Olgin, J. E., Kalman, J. M., Fitzpatrick, A. P., & Lesh, M. D. (1995). Role of right atrial structures as barriers to conduction during human type 1 atrial flutter. Activation and entrainment mapping guided by intracardiac echocardiography. Circulation, 92, 1839–1848.PubMedGoogle Scholar
  5. 5.
    Nakagawa, H., Lazzara, R., Khastgir, T., Beckman, K. J., McClelland, J. H., Imai, S., et al. (1996). Role of the tricuspid annulus and the eustachian valve/ridge on atrial flutter. Circulation, 94, 407–424.PubMedGoogle Scholar
  6. 6.
    Cosio, F. G., Arribas, F., Lopez-Gil, M., & Palacios, J. (1996). Atrial flutter mapping and ablation I. Studying atrial flutter mechanisms by mapping and entrainment. Pacing and Clinical Electrophysiology, 19, 841–853.PubMedCrossRefGoogle Scholar
  7. 7.
    Olgin, J. E., Kalman, J. M., & Lesh, M. D. (1996). Conduction barriers in human atrial flutter: Correlation of electrophysiology and anatomy. Journal of Cardiovascular Electrophysiology, 7, 1112–1126.PubMedGoogle Scholar
  8. 8.
    Cosio, F. G., Arribas, F., Lopez-Gil, M., & Palacios, J. (1996). Atrial flutter mapping and ablation II. Radiofrequency ablation of atrial circuits. Pacing and Clinical Electrophysiology, 19, 965–975.PubMedCrossRefGoogle Scholar
  9. 9.
    Kalman, J. M., Olgin, J. E., Saxon, L. A., Fisher, W. G., Lee, R. J., & Lesh, M. D. (1996). Activation and entrainment mapping defines the tricuspid annulus as the anterior barrier in typical atrial flutter. Circulation, 94, 398–406.PubMedGoogle Scholar
  10. 10.
    Poty, H., Saoudi, N., Nair, M., Anselme, F., & Letac, B. (1996). Radiofrequency catheter ablation of atrial flutter. Further insights into the various types of isthmus block: Application to ablation during sinus rhythm. Circulation, 94, 3204–3213.PubMedGoogle Scholar
  11. 11.
    Cauchemez, B., Haissaguerre, M., Fisher, B., Thomas, O., Clementy, J., & Coumel, P. (1996). Electrophysiological effects of catheter ablation of inferior vena cava-tricuspid annulus isthmus in common atrial flutter. Circulation, 93, 284–294.PubMedGoogle Scholar
  12. 12.
    Shah, D. C., Jais, P., Haissaguerre, M., Chouairi, S., Takahashi, A., Hocini, M., et al. (1997). Three-dimensional mapping of the common atrial flutter circuit in the right atrium. Circulation, 96, 3904–3912.PubMedGoogle Scholar
  13. 13.
    Natale, A., Newby, K. H., Pisano, E., Leonelli, F., Fanelli, R., Potenza, D., et al. (2000). Prospective randomized comparison of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter. Journal of the American College of Cardiology, 35, 1898–1904.PubMedCrossRefGoogle Scholar
  14. 14.
    Poty, H., Saoudi, N., Abdel Aziz, A., Nair, M., & Letac, B. (1995). Radiofrequency catheter ablation of type 1 atrial flutter. Prediction of late success by electrophysiological criteria. Circulation, 92, 1389–1392.PubMedGoogle Scholar
  15. 15.
    Schumacher, B., Pfeiffer, D., Tebbenjohanns, J., Lewalter, T., Jung, W., & Luderitz, B. (1998). Acute and long-term effects of consecutive radiofrequency applications on conduction properties of the subeustachian isthmus in a type I atrial flutter. Journal of Cardiovascular Electrophysiology, 9, 152–163.PubMedGoogle Scholar
  16. 16.
    Tai, C., Chen, S. A., Chiang, C. E., Lee, S. H., Wen, Z. C., Huang, J. L., et al. (1998). Long-term outcome of radiofrequency catheter ablation for typical atrial flutter. Risk prediction of recurrent arrhythmias. Journal of Cardiovascular Electrophysiology, 9, 115–121.PubMedGoogle Scholar
  17. 17.
    Saoudi, N., Poty, H., Anselme, F., Nair, M., Abdel Azziz, A., & Letac, B. (1998). Evolution of concepts and techniques in radiofrequency catheter ablation for the common type of atrial flutter. In N. Saoudi, W. Schels, & N. El-Scherif (Eds.), Atrial flutter and fibrillation: From basic to clinical applications. Armonk, NY: Futura.Google Scholar
  18. 18.
    Shah, D., Haissaguerre, M., Jais, P., Takahashi, A., Hocini, M., & Clementy, J. (1999). High-density mapping of activation through an incomplete isthmus ablation line. Circulation, 99, 211–215.PubMedGoogle Scholar
  19. 19.
    Cabrera, J. A., Sanchez-Quintana, D., Ho, S. Y., Medina, A., Wanguemert, F., Gross, E., et al. (1999). Angiographic anatomy of the inferior right isthmus in patients with and without history of common atrial flutter. Circulation, 99, 3017–3023.PubMedGoogle Scholar
  20. 20.
    Heidbuchel, H., Willems, R., Van Rensburg, H., Adams, J., Ector, H., & Van de Werf, F. (2000). Right atrial angiographic evaluation of the posterior isthmus: Relevance for ablation of typical atrial flutter. Circulation, 101, 2178–2184.PubMedGoogle Scholar
  21. 21.
    Da Costa, A., Faure, E., Thevenin, J., Messier, M., Bernard, S., Abdel, K., et al. (2004). Effect of isthmus anatomy and ablation catheter on radiofrequency catheter ablation of the cavotricuspid isthmus. Circulation, 110, 1030–1035.PubMedCrossRefGoogle Scholar
  22. 22.
    Da Costa, A., Romeyer-Bouchard, C., Dauphinot, V., Lipp, D., Abdellaoui, L., Messier, M., et al. (2006). Cavotricuspid isthmus angiography predicts atrial flutter ablation efficacy in 281 patients randomized between 8 mm- and externally irrigated-tip catheter. European Heart Journal, 27, 1833–1840.PubMedCrossRefGoogle Scholar
  23. 23.
    Okumura, Y., Watanabe, I., Yamada, T., Ohkubo, K., Masaki, R., Sugimura, H., et al. (2004). Comparison of coronary sinus morphology in patients with and without atrioventricular nodal reentrant tachycardia by intracardiac echocardiography. Journal of Cardiovascular Electrophysiology, 15, 269–273.PubMedCrossRefGoogle Scholar
  24. 24.
    Okumura, Y., Watanabe, I., Yamada, T., Ohkubo, K., Sugimura, H., Hashimoto, K., et al. (2004). Relationship between anatomic location of the crista terminalis and double potentials recorded during atrial flutter: Intracardiac echocardiographic analysis. Journal of Cardiovascular Electrophysiology, 15, 1426–1432.PubMedCrossRefGoogle Scholar
  25. 25.
    Cabrera, J. A., Sanchez-Quintana, D., Ho, S. Y., Medina, A., & Anderson, R. H. (1998). The architecture of the atrial musculature between the orifice of the inferior caval vein and the tricuspid valve: the anatomy of the isthmus. Journal of Cardiovascular Electrophysiology, 9, 1186–1195.PubMedGoogle Scholar
  26. 26.
    Waki, K., Saito, T., & Becker, A. E. (2000). Right atrial flutter isthmus revisited: Normal anatomy favors nonuniform anisopropic conduction. Journal of Cardiovascular Electrophysiology, 11, 90–94.PubMedGoogle Scholar
  27. 27.
    Scaglione, M., Caponi, D., Di Donna, P., Riccardi, R., Bocchiardo, M., Azzaro, G., et al. (2004). Typical atrial flutter ablation outcome: Correlation with isthmus anatomy using intracardiac echo 3D reconstruction. Europace, 6, 407–417.PubMedCrossRefGoogle Scholar
  28. 28.
    Okishige, K., Kawabata, M., Yamashiro, K., Ohshiro, C., Umayahara, S., Gotoh, M., et al. (2005). Clinical study regarding the anatomical structures of the right atrial isthmus using intra-cardiac echocardiography: Implication for catheter ablation of common atrial flutter. Journal of Interventional Cardiac Electrophysiology, 12, 9–12.PubMedCrossRefGoogle Scholar
  29. 29.
    Spach, M. S., & Dolber, P. C. (1986). Relating extracellular potentials and their derivatives to anisotropic propagation at a microscopical level in human cardiac muscle. Evidence for electrical uncoupling side-to-side fiber connections with increasing age. Circulation Research, 58, 356–371.PubMedGoogle Scholar
  30. 30.
    Jais, P., Shah, D. C., Haissaguerre, M., Hocini, M., Garrigue, S., Le Metayer, P., et al. (2000). Prospective randomized comparison of irrigated-tip versus conventional-tip catheters for ablation of common flutter. Circulation, 101, 772–776.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Yasuo Okumura
    • 1
  • Ichiro Watanabe
    • 1
  • Sonoko Ashino
    • 1
  • Masayoshi Kofune
    • 1
  • Takeshi Yamada
    • 1
  • Yasuhiro Takagi
    • 1
  • Kazunori Kawauchi
    • 1
  • Kimie Okubo
    • 1
  • Kenichi Hashimoto
    • 1
  • Atsushi Shindo
    • 1
  • Hidezou Sugimura
    • 1
  • Toshiko Nakai
    • 1
  • Satoshi Saito
    • 1
  1. 1.Department of Cardiovascular DiseaseNihon University School of MedicineTokyoJapan

Personalised recommendations