Mechanisms of organized left atrial tachycardias occurring after pulmonary vein isolation
Abstract
BACKGROUND: A proarrhythmic consequence of pulmonary vein (PV) isolation can be a recurrent organized left atrial (LA) tachycardia after ablation. This arrhythmia is frequently referred to as "left atrial flutter," but the mechanism and best ablation strategy have not been determined. METHODS AND RESULTS: Isolation of arrhythmogenic PVs was initially performed by segmental ostial PV ablation guided by a circular mapping catheter in 341 patients. Patients whose predominant recurrent arrhythmia was a persistent organized tachycardia returned for mapping and ablation. Recurrent organized LA tachycardias (cycle length 253+/-33 ms, range 213 to 328 ms) occurred in 10 (2.9%) of 341 patients (age 59+/-9 years, 1 woman). Mapping was consistent with a focal origin in 8 patients and with macroreentry in 1 patient and was unclear in 1 patient owing to degeneration to atrial fibrillation. Focal tachycardias originated from reconnected segments of prior isolated PVs (6 patients), the posterior LA (1 patient), or the superior septum (1 patient). Focal atrial tachycardias were ablated with point lesions that targeted the earliest activation. All reconnected PVs were also reisolated. Reentrant LA flutter occurred around the left PVs in 1 patient. After 6.7+/-2.3 months of follow-up, 9 (90%) of 10 patients were arrhythmia free (4 of whom were taking antiarrhythmic drug therapy), and one was having recurrent atrial fibrillation. CONCLUSIONS: Recurrent organized LA tachycardia after PV isolation is uncommon and typically has a focal origin from reconnected PV ostia. Reisolation of the PV and ablation of non-PV foci are sufficient to treat this proarrhythmia. Linear lesions are only required when a macroreentrant mechanism is present.
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In atrial flutter after atrial fibrillation ablation, more than one tachycardia mechanism often coexists, both macroreentrant and focal, sometimes making circuit identification difficult, particularly when entrainment maneuvers change activation.
“In post-AF ablation AFL, more than one tachycardia mechanisms often coexist, both MRT and focal, 157,203 making sometimes difficult to identify the circuits' structures, particularly when entrainment manoeuvres result in changes in activation.”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [203]
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Flutter Localized to the Anterior Left Atrium After Catheter Ablation of Atrial Fibrillation
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Venice Chart International Consensus Document on Atrial Fibrillation Ablation: 2011 Update
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Clinical Significance of Early Recurrences of Atrial Tachycardia After Atrial Fibrillation Ablation
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Electroanatomic Mapping of the Intercaval Bundle in Atrial Fibrillation
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Inducibility of Atrial Fibrillation and Flutter Following Pulmonary Vein Ablation
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- Authors
- Gerstenfeld, E. P., Callans, D. J., Dixit, S., Russo, A. M., Nayak, H., Lin, D., Pulliam, W., Siddique, S., & Marchlinski, F. E.
- Affiliations
- Hospital of the University of Pennsylvania (US)
- ORCID
- Venue
- Circulation
- Published
- 2004-09-14
- Volume
- 110
- Issue
- 11
- Pages
- 1351-1357
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W1997307266
- Cited by
- 300
- References
- 22
- Citations by year
- 2026: 5 · 2025: 2 · 2024: 7 · 2023: 6 · 2022: 9 · 2021: 10 · 2020: 10 · 2019: 11 · 2018: 9 · 2017: 14 · 2016: 10 · 2015: 19 · 2014: 16 · 2013: 13 · 2012: 23
- FWCI
- 13.72
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Keywords
- pulmonary vein isolation, left atrial flutter, drug-induced arrhythmia, focal atrial tachycardia, macroreentry, atrial fibrillation, catheter ablation
- MeSH terms
- Adult, Aged, Atrial Fibrillation, Electrocardiography, Female, Follow-Up Studies, Heart Atria, Heart Conduction System, Humans, Male, Middle Aged, Postoperative Complications, Pulmonary Veins, Recurrence, Regeneration, Tachycardia, Supraventricular, Catheter Ablation, Atrial Premature Complexes, Electrophysiologic Techniques, Cardiac
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