Role of Right Atrial Endocardial Structures as Barriers to Conduction During Human Type I Atrial Flutter: Activation and Entrainment Mapping Guided by Intracardiac Echocardiography

Olgin, Jeffrey E.; Kalman, Jonathan M.; Fitzpatrick, Adam P.; Lesh, Michael D.

doi:10.1161/01.cir.92.7.1839

Cited by 500Cardiac Arrhythmias and TreatmentsCardiac electrophysiology and arrhythmiasAtrial Fibrillation Management and Outcomes

Role of Right Atrial Endocardial Structures as Barriers to Conduction During Human Type I Atrial Flutter: Activation and Entrainment Mapping Guided by Intracardiac Echocardiography

Olgin, Jeffrey E., Kalman, Jonathan M., Fitzpatrick, Adam P., Lesh, Michael D.·1995·Circulation

DOI 10.1161/01.cir.92.7.1839

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Abstract

BACKGROUND: The importance of barriers in atrial flutter has been demonstrated in animals. We used activation and entrainment mapping, guided by intracardiac echocardiography (ICE), to determine whether the crista terminalis (CT) and eustachian ridge (ER) are barriers to conduction during typical atrial flutter in humans. METHODS AND RESULTS: In eight patients, ICE was used to guide the placement of 20-pole and octapolar catheters along the CT and interatrial septum and a roving catheter to nine sites: just posterior (1) and anterior (2) to the CT along the lateral right atrium, at the fossa ovalis (3), and just posterior and anterior to the ER at the low posterolateral (4 and 5), low posterior (6 and 7), and low posteromedial (8 and 9) right atrium. Entrainment was performed, and each site was considered within the flutter circuit if the postpacing interval-flutter cycle length (PPI-FCL) and the stimulus time-activation time (stim time-act time) were < 10 msec. Split potentials were recorded along the CT with components activated in a low-to-high pattern and a high-to-low pattern. Conduction times, as percentage of FCL, were significantly different at sites on either side of the CT and ER: site 1 (33 +/- 13%) and site 2 (43 +/- 12%) (P = .02), site 4 (48 +/- 24%) and site 5 (75 +/- 8.9%) (P = .02), and site 6 (22 +/- 10%) and site 7 (82 +/- 5.3%) (P = .0009). During entrainment, no surface fusion was observed at sites 5, 7, or 9. The PPI-FCL and stim time-act time were not significantly different than 0 at sites 2, 7, 5, or 9, indicating that they were within the flutter circuit, whereas sites 1, 3, 4, and 6 were not. CONCLUSIONS: ICE enabled the correlation of functional electrophysiological properties with specific anatomic landmarks, identifying the CT and ER as barriers to conduction during human atrial flutter.

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The diameter of the circuit necessary to sustain reentry depends on the area or line of block in the posterior RA, consistent with increased thickness and increased capacity to block transverse conduction at the crista terminalis.
“The diameter of the circuit, necessary to sustain reentry is dependent on the presence of the area or line of block in the posterior RA, which is in keeping with an increased thickness, 128,129 and the increased capacity to block transverse conduction at the crista terminalis.123,130”
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 [123]
The reentry mechanism of typical AFL is supported by a line of conduction block in the posterior RA extending from IVC toward SVC, most often related to anisotropic conduction at the crista terminalis, though other posterior RA structures may play a role.
“The reentry mechanism is supported by a line of conduction block in the posterior RA, extending from the IVC toward the SVC, most often related to anisotropic conduction at the crista terminalis, 123 although other structures of the posterior RA may also play a role.124”
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 [123]

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Authors: Olgin, J. E., Kalman, J. M., Fitzpatrick, A. P., & Lesh, M. D.
Affiliations: University of California, San Francisco (US)
ORCID: Olgin, Jeffrey E.
Kalman, Jonathan M.
Venue: Circulation
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 1995-10
Volume: 92
Issue: 7
Pages: 1839-1848
ISSN: 0009-7322 (ISSN-L)
1524-4539
DOI: 10.1161/01.cir.92.7.1839
OpenAlex: W2168770908
Cited by: 500
References: 38
Citations by year: 2026: 4 · 2025: 4 · 2024: 8 · 2023: 4 · 2022: 3 · 2021: 8 · 2020: 3 · 2019: 9 · 2018: 2 · 2017: 8 · 2016: 6 · 2015: 5 · 2014: 6 · 2013: 10 · 2012: 21
FWCI: 28.99
Type: journal article
Language: en
Open access: closed
Locations: Circulation (publishedVersion)
PubMed (publishedVersion)
Funders: National Institutes of Health (5r29hl045664-03)
National Heart, Lung, and Blood Institute (HL 45664)
Topics: Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
Keywords: atrial flutter, crista terminalis, Eustachian ridge, right atrium, activation mapping, entrainment mapping, intracardiac echocardiography, postpacing interval
MeSH terms: Aged, Atrial Flutter, Cardiac Pacing, Artificial, Echocardiography, Electrocardiography, Endocardium, Female, Heart Atria, Cardiac Catheterization, Heart Conduction System, Humans, Male, Atrial Function, Right, Catheter Ablation

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Role of Right Atrial Endocardial Structures as Barriers to Conduction During Human Type I Atrial Flutter: Activation and Entrainment Mapping Guided by Intracardiac Echocardiography

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