This case demonstrates the use of entrainment maneuvers to diagnose and successfully treat intra-isthmus reentry causing recurrent typical atrial flutter after previous CTI ablation.
Entrainment mapping may aid diagnosis of intra-isthmus reentry in recurrent flutter; hypothesis-generating and requires prospective validation before wider adoption.
An 80-year-old man was admitted for cardiac failure and recurrence of electrocardiographically typical atrial flutter (figure, upper left panel). Six months earlier he has had cavo-tricuspid isthmus (CTI) ablation with successful block. A new electrophysiological study showed counter-clockwise (CCW) tricuspid annulus activation and proximal-to-distal coronary sinus (CS) activation (upper right panel), compatible with CCW typical flutter recurrence. Entrainment manoeuvres demonstrated reentry as evidenced by constant fusion and progressive fusion of the intracardiac electrograms during pacing at different cycle length (CL). Based on post-pacing interval (PPI)—CL differences, only the septal CTI and possibly the proximal CS were part of the circuit. The middle pane of the figure depicts the differences between PPI and the flutter CL at all the pacing sites. The maximal duration bipolar electrogram at the septal CTI spanned over 58% of the CL (lower panel). One radiofrequency application at this site terminated the flutter. Pacing manoeuvres (600 ms) in sinus rhythm showed complete bi-directional CTI block. Conflict of interest: none declared.
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Lațcu et al. (2013) studied this question.
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