Organized Left Atrial Tachyarrhythmia During Stepwise Linear Ablation for Atrial Fibrillation

INTRODUCTION: This study attempted to delineate the mechanism of organized left atrial tachyarrhythmia (AT) during stepwise linear ablation for atrial fibrillation (AF) using noncontact mapping. METHODS AND RESULTS: Eighty patients in whom organized ATs developed or induced during stepwise linear ablation for AF were enrolled. Left atrial (LA) activation during ATs was mapped using noncontact mapping. Radiofrequency (RF) energy was delivered to the earliest activation site or narrowest part of the reentrant circuit of ATs. A total of 146 ATs were mapped. Four ATs were characterized as a focal mechanism (cycle length (CL): 225 +/- 49 ms). A macroreentrant mechanism was confirmed in the remaining 142 ATs. LA activation time accounted for 100% of CL (205 +/- 37 ms). All 142 ATs used the conduction gaps in the basic figure-7 lesion line. There were three types of circuits classified based on the gap location. Type I (n = 68) used gaps at the ridge between left atrial appendage (LAA) and left superior pulmonary vein (LSPV). Type II (n = 50) used gaps on the LA roof. Type III (n = 24) passed through gaps in the mitral isthmus. Ablation at these gaps eliminated 130 ATs. During the follow-up period of 16.2 +/- 6.7 months, 82.5% of the 80 patients were in sinus rhythm. CONCLUSION: The majority of left ATs developed during stepwise linear ablation for AF are macroreentrant through conduction gaps in the figure-7 lesion line, especially at the LAA-LSPV ridge. Noncontact activation mapping can identify these gaps accurately and quickly to target effective catheter ablation.