Microreentrant left atrial tachycardia circuit mapped with an ultra-high-density mapping system

Figures

• 

  Figure 1. Electrical reconnection of left-sided pulmonary veins. Six sequential activation maps during pacing from the coronary sinus catheter demonstrating conduction into the left pulmonary veins. Conduction can be seen to cross the gap in the line of the previous wide area circumferential ablation (WACA) into the pulmonary veins (PVs). LLPV = left lower pulmonary vein; LUPV = left upper pulmonary vein.

• 

  Figure 2. Microreentrant atrial tachycardia anterior to left-sided pulmonary veins. During mapping, the patient developed an atrial tachycardia (cycle length [CL] 220 ms). A high-density Rhythmia map was performed around the left pulmonary veins, which demonstrated a microreentrant circuit anterior to the left pulmonary veins, near the site of the gap in the wide area circumferential ablation line in Figure 1. The 4 panels are sequential activation maps demonstrating the microreentrant circuit. The corresponding bipolar voltage map during atrial tachycardia is also shown. LLPV = left lower pulmonary vein; LUPV = left upper pulmonary vein.

• 

  Figure 3. Fractionated electrograms spanning the entire tachycardia cycle length within the microreentrant circuit. A: Rhythmia isochronal activation map showing the location of the microreentrant circuit. B: Bipolar electrograms obtained with the Orion catheter at 5 locations within the circuit (1–5) shown in panel A. The black column denotes the window of interest (WOI) for activation mapping, and the Rhythmia auto-annotated activation times are shown by vertical yellow lines. Activation times are seen to span the entire tachycardia cycle length, with progressive activation denoted by blue arrows. The area bounded by the 5 points measured 0.32 cm2. The coronary sinus (CS) reference electrogram and surface electrocardiogram lead V6 are also shown. C: A cluster of radiofrequency lesions were delivered at the site of the microreentrant circuit, which rendered the arrhythmia subsequently noninducible. D: Intracardiac electrograms during entrainment near the site of the microreentrant circuit. Pacing was delivered from the Orion catheter (poles H4–5) at 200 ms, which was 20 ms shorter than the tachycardia cycle length of 220 ms. Because of amplifier saturation, the postpacing interval was…