Catheter ablation of atrial tachycardia

INTRODUCTION

Any supraventricular tachycardia (SVT) that requires only atrial tissue for its initiation and maintenance can properly be considered an atrial tachyarrhythmia. Although a relatively uncommon form of SVT, atrial tachycardia tends to be refractory to pharmacologic therapy and is therefore frequently treated with ablative therapy.

Current catheter ablative techniques have evolved from open surgical techniques in which the arrhythmia focus was identified using intraoperative mapping and then excised [1,2]. Direct current (DC) shock catheter ablation (fulguration) was used for a short time in small numbers of patients with atrial tachycardia; this technique has been completely supplanted by radiofrequency (RF) catheter ablation.

Radiofrequency catheter ablation (RFCA) techniques and outcomes in patients with atrial tachycardia will be reviewed here. Ablative techniques for the management of atrial fibrillation, and atrial flutter, both typical and atypical flutter, are discussed separately. (See "Radiofrequency catheter ablation to prevent recurrent atrial fibrillation" and "Maintenance of sinus rhythm after cardioversion in atrial flutter".)

ATRIAL TACHYCARDIAS AMENABLE TO CATHETER ABLATION

Atrial tachycardia may be unifocal or multifocal; some unifocal tachycardias originate in or around the sinus node.

  • Unifocal (or ectopic) atrial tachycardia may have an automatic or reentrant mechanism, and a paroxysmal or incessant pattern (waveform 1 and waveform 2 and waveform 3). Most varieties of unifocal atrial tachycardia are amenable to catheter ablation. Like atrial fibrillation, focal atrial tachycardia may arise from the pulmonary venous ostia [3,4]. The pathophysiology appears to be related, but not identical, to that of focal AF [3]. (See "Intraatrial reentrant tachycardia" and "Focal atrial tachycardia" and 'Indications for catheter ablation' below and "Radiofrequency catheter ablation to prevent recurrent atrial fibrillation".)
  • Sinoatrial node reentrant tachycardia (SNRT) is a specific type of unifocal atrial tachycardia in which sinoatrial (SA) nodal or peri-SA nodal tissue is part of the reentry circuit; this results in P waves during tachycardia which may be indistinguishable from normal sinus P waves [5,6]. (See "Sinoatrial nodal reentrant tachycardia (SANRT)".)
  • Inappropriate sinus tachycardia (IST), also known as chronic nonparoxysmal sinus tachycardia, is a distinct syndrome in which the resting sinus rate is elevated and there is an exaggerated chronotropic response to exercise [7]. Although IST is most often treated with beta blockers, ablation may be considered in refractory patients. (See "Sinus tachycardia".)
  • Occasionally, patients with more than one discrete ectopic atrial focus are candidates for curative ablation. Multifocal atrial tachycardia (MAT), however, is due to abnormal automaticity or triggered activity throughout the atria, and is therefore not curable with standard catheter techniques (waveform 4). Refractory patients with MAT may benefit from complete atrioventricular junctional ablation and permanent pacemaker implantation or AV nodal modification [8]. (See "Multifocal atrial tachycardia".)

           

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Literature review current through: Apr 2013. | This topic last updated: Apr 5, 2012.
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References
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  1. Coumel P, Aigueperse J, Perrault MA, et al. [Detection and attempted surgical exeresis of a left auricular ectopic focus with refractory tachycardia. Favorable outcome]. Ann Cardiol Angeiol (Paris) 1973; 22:189.
  2. Prager NA, Cox JL, Lindsay BD, et al. Long-term effectiveness of surgical treatment of ectopic atrial tachycardia. J Am Coll Cardiol 1993; 22:85.
  3. Kistler PM, Sanders P, Fynn SP, et al. Electrophysiological and electrocardiographic characteristics of focal atrial tachycardia originating from the pulmonary veins: acute and long-term outcomes of radiofrequency ablation. Circulation 2003; 108:1968.
  4. Yamada T, Murakami Y, Muto M, et al. Electrophysiologic characteristics of atrial tachycardia originating from the right pulmonary veins or posterior right atrium: double potentials obtained from the posterior wall of the right atrium can be useful to predict foci of atrial tachycardia in right pulmonary veins or posterior right atrium. J Cardiovasc Electrophysiol 2004; 15:745.
  5. Narula OS. Sinus node re-entry: a mechanism for supraventricular tachycardia. Circulation 1974; 50:1114.
  6. Gomes JA, Mehta D, Langan MN. Sinus node reentrant tachycardia. Pacing Clin Electrophysiol 1995; 18:1045.
  7. Krahn AD, Yee R, Klein GJ, Morillo C. Inappropriate sinus tachycardia: evaluation and therapy. J Cardiovasc Electrophysiol 1995; 6:1124.
  8. Ueng KC, Lee SH, Wu DJ, et al. Radiofrequency catheter modification of atrioventricular junction in patients with COPD and medically refractory multifocal atrial tachycardia. Chest 2000; 117:52.
  9. Morady F. Radio-frequency ablation as treatment for cardiac arrhythmias. N Engl J Med 1999; 340:534.
  10. Chiladakis JA, Vassilikos VP, Maounis TN, et al. Successful radiofrequency catheter ablation of automatic atrial tachycardia with regression of the cardiomyopathy picture. Pacing Clin Electrophysiol 1997; 20:953.
  11. Gillette PC, Wampler DG, Garson A Jr, et al. Treatment of atrial automatic tachycardia by ablation procedures. J Am Coll Cardiol 1985; 6:405.
  12. Guidelines for Clinical Intracardiac Electrophysiological and Catheter Ablation Procedures. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. (Committee on Clinical Intracardiac Electrophysiologic and Catheter Ablation Procedures). Developed in collaboration with the North American Society of Pacing and Electrophysiology. Circulation 1995; 92:673.
  13. Lesh MD. Radiofrequency catheter ablation of atrial tachycardia and flutter. In: Cardiac Electrophysiology: From Cell to Bedside, 2nd ed, Zipes DP, Jalife J (Eds), WB Saunders, Philadelphia 1995. p.1461.
  14. Lesh MD, Van Hare GF, Epstein LM, et al. Radiofrequency catheter ablation of atrial arrhythmias. Results and mechanisms. Circulation 1994; 89:1074.
  15. Kalman JM, Olgin JE, Karch MR, et al. "Cristal tachycardias": origin of right atrial tachycardias from the crista terminalis identified by intracardiac echocardiography. J Am Coll Cardiol 1998; 31:451.
  16. Schmitt C, Zrenner B, Schneider M, et al. Clinical experience with a novel multielectrode basket catheter in right atrial tachycardias. Circulation 1999; 99:2414.
  17. Sanders P, Hocini M, Jaïs P, et al. Characterization of focal atrial tachycardia using high-density mapping. J Am Coll Cardiol 2005; 46:2088.
  18. Tang CW, Scheinman MM, Van Hare GF, et al. Use of P wave configuration during atrial tachycardia to predict site of origin. J Am Coll Cardiol 1995; 26:1315.
  19. De Ponti R, Zardini M, Storti C, et al. Trans-septal catheterization for radiofrequency catheter ablation of cardiac arrhythmias. Results and safety of a simplified method. Eur Heart J 1998; 19:943.
  20. Daoud EG, Kalbfleisch SJ, Hummel JD. Intracardiac echocardiography to guide transseptal left heart catheterization for radiofrequency catheter ablation. J Cardiovasc Electrophysiol 1999; 10:358.
  21. Schmitt H, Weber S, Schwab JO, et al. Diagnosis and ablation of focal right atrial tachycardia using a new high-resolution, non-contact mapping system. Am J Cardiol 2001; 87:1017.
  22. Paul T, Windhagen-Mahnert B, Kriebel T, et al. Atrial reentrant tachycardia after surgery for congenital heart disease: endocardial mapping and radiofrequency catheter ablation using a novel, noncontact mapping system. Circulation 2001; 103:2266.
  23. Higa S, Tai CT, Lin YJ, et al. Focal atrial tachycardia: new insight from noncontact mapping and catheter ablation. Circulation 2004; 109:84.
  24. Marchlinski F, Callans D, Gottlieb C, et al. Magnetic electroanatomical mapping for ablation of focal atrial tachycardias. Pacing Clin Electrophysiol 1998; 21:1621.
  25. Natale A, Breeding L, Tomassoni G, et al. Ablation of right and left ectopic atrial tachycardias using a three-dimensional nonfluoroscopic mapping system. Am J Cardiol 1998; 82:989.
  26. Hoffmann E, Reithmann C, Nimmermann P, et al. Clinical experience with electroanatomic mapping of ectopic atrial tachycardia. Pacing Clin Electrophysiol 2002; 25:49.
  27. Delacretaz E, Ganz LI, Soejima K, et al. Multi atrial maco-re-entry circuits in adults with repaired congenital heart disease: entrainment mapping combined with three-dimensional electroanatomic mapping. J Am Coll Cardiol 2001; 37:1665.
  28. Friedman PL. Catheter cryoablation of cardiac arrhythmias. Curr Opin Cardiol 2005; 20:48.
  29. Wong T, Segal OR, Markides V, et al. Cryoablation of focal atrial tachycardia originating close to the atrioventricular node. J Cardiovasc Electrophysiol 2004; 15:838.
  30. Marrouche NF, Beheiry S, Tomassoni G, et al. Three-dimensional nonfluoroscopic mapping and ablation of inappropriate sinus tachycardia. Procedural strategies and long-term outcome. J Am Coll Cardiol 2002; 39:1046.
  31. Schweikert RA, Saliba WI, Tomassoni G, et al. Percutaneous pericardial instrumentation for endo-epicardial mapping of previously failed ablations. Circulation 2003; 108:1329.
  32. Koplan BA, Parkash R, Couper G, Stevenson WG. Combined epicardial-endocardial approach to ablation of inappropriate sinus tachycardia. J Cardiovasc Electrophysiol 2004; 15:237.
  33. Kay GN, Chong F, Epstein AE, et al. Radiofrequency ablation for treatment of primary atrial tachycardias. J Am Coll Cardiol 1993; 21:901.
  34. Chen SA, Chiang CE, Yang CJ, et al. Sustained atrial tachycardia in adult patients. Electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation. Circulation 1994; 90:1262.
  35. Poty H, Saoudi N, Haissaguerre M, et al. Radiofrequency catheter ablation of atrial tachycardias. Am Heart J 1996; 131:481.
  36. Chen SA, Tai CT, Chiang CE, et al. Focal atrial tachycardia: reanalysis of the clinical and electrophysiologic characteristics and prediction of successful radiofrequency ablation. J Cardiovasc Electrophysiol 1998; 9:355.
  37. Anguera I, Brugada J, Roba M, et al. Outcomes after radiofrequency catheter ablation of atrial tachycardia. Am J Cardiol 2001; 87:886.
  38. Scheinman MM, Huang S. The 1998 NASPE prospective catheter ablation registry. Pacing Clin Electrophysiol 2000; 23:1020.
  39. Sanders WE Jr, Sorrentino RA, Greenfield RA, et al. Catheter ablation of sinoatrial node reentrant tachycardia. J Am Coll Cardiol 1994; 23:926.
  40. Ivanov MY, Evdokimov VP, Vlasenco VV. Predictors of successful radiofrequency catheter ablation of sinoatrial tachycardia. Pacing Clin Electrophysiol 1998; 21:311.
  41. Lee RJ, Kalman JM, Fitzpatrick AP, et al. Radiofrequency catheter modification of the sinus node for "inappropriate" sinus tachycardia. Circulation 1995; 92:2919.
  42. Man KC, Knight B, Tse HF, et al. Radiofrequency catheter ablation of inappropriate sinus tachycardia guided by activation mapping. J Am Coll Cardiol 2000; 35:451.
  43. Shen WK, Low PA, Jahangir A, et al. Is sinus node modification appropriate for inappropriate sinus tachycardia with features of postural orthostatic tachycardia syndrome? Pacing Clin Electrophysiol 2001; 24:217.
  44. Lai LP, Lin JL, Chen TF, et al. Clinical, electrophysiological characteristics, and radiofrequency catheter ablation of atrial tachycardia near the apex of Koch's triangle. Pacing Clin Electrophysiol 1998; 21:367.