Focal Atrial Tachycardia from the Right Superior Pulmonary Vein with Stable P Wave Morphology and Cycle Length: the Problem of Discriminating between a Right and Left Origin


This is a 62-year-old female patient with a long history of arrhythmia. Eleven years earlier, in our centre, she underwent ablation of a slow atrioventricular node pathway for a frequently recurrent and drug-refractory common atrioventricular nodal reentrant tachycardia. The procedure was successful and follow-up was initially uneventful. Six years later, her complaints of palpitations resumed and were electrocardiographically documented as atrial tachycardia. The palpitations worsened during the following three years and the patient was referred to another centre for an electrophysiology procedure. There, a focal atrial tachycardia was diagnosed and the patient underwent two unsuccessful ablation procedures in the posterior right atrium. In the following 24 months, antiarrhythmic drug therapy with flecainide, sotalol and then with amiodarone did not prevent recurrences and the arrhythmia worsened, becoming in some cases iterative-incessant. Surface electrocardiograms showed the same tachycardia morphology (Figs. 1,2) with flat P waves in leads I and aVL, negative in aVR and positive in all the other leads, not very dissimilar from the sinus morphology (Fig. 1a). In different recordings, the arrhythmia showed a variable presentation and cycle length, i.e. sustained with 2:1 atrioventricular conduction and a regular atrial cycle of 300 ms (Fig. 1b), or iterative with short tachycardia runs (Fig. 1c) or, on occasion, sustained with a beat-to-beat variation of the cycle length from a minimum of 280 ms to a maximum of 460 ms (Fig. 2). Finally, the patient was referred to our institution for further evaluation. An echocardiogram showed no dilatation of the heart chambers and ventricular function was preserved. This suggested that the ventricular repolarization abnormality observed on surface electrocardiogram should have been interpreted as tachycardia-related rather than an expression of the presence of structural heart disease or tachycardiomyopathy.


Pulmonary Vein Sinus Rhythm Left Atrium Coronary Sinus Atrial Tachycardia 
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