Right‐Sided Free Wall Accessory Pathway Refractory to Conventional Catheter Ablation: Lessons From 3‐Dimensional Electroanatomic Mapping

INTRODUCTION: the aim of this study was to delineate the electroanatomic substrates of right-sided free wall (RFW) accessory pathways (APs) that were refractory to conventional catheter ablation utilizing 3-dimensional (3-D) mapping. METHODS AND RESULTS: eleven patients with RFW APs that failed initial conventional catheter ablation(s) by a mean of 1.9 ± 0.5 attempts were enrolled in the study. Electroanatomic mapping of the right atrium was performed during orthodromic reciprocating tachycardia in 3 patients and right ventricular pacing in 8 patients. The earliest atrial activation site, which represented the atrial insertion of the AP, was separated from the tricuspid annulus by an average of 14.3 ± 3.9 mm, and the local activation time was 27.8 ± 17.0 ms earlier than that of the corresponding annular point. One patient exhibited an AP with wide branching on the atrial side. RF ablation with an irrigated catheter successfully interrupted AP conduction in all patients without complications. CONCLUSIONS: RFW APs resistant to conventional catheter ablation might be due to unique anatomic AP features such as more epicardial course at the annulus level with atrial insertion distant from the tricuspid annulus. Electroanatomic mapping is helpful to accurately localize the atrial insertion sites of these APs and facilitates catheter ablation.