Unusual use of a tip-versatile ablation catheter in the ablation of peri-nodal atrial tachycardia

A 61-year-old woman underwent repeat electrophysiology study for paroxysmal atrial tachycardia. Tachycardia was readily inducible and mapped to the peri-nodal region of the right atrial septum, in close proximity to the His bundle electrogram (the left atrium was mapped via a patent foramen ovale). Adequate stability for ablation could not be achieved with a 3.5 mm D curve ablation catheter, despite extensive attempts by an experienced operator. A tip-versatile ablation catheter (T-VAC; Medtronic) was positioned along the atrial septum. This allowed delivery of multi-polar, duty-cycled bipolar:unipolar (4:1) radio-frequency energy to the site of earliest atrial activation, via mid-proximal electrode bipoles (TV3-5), despite close proximity to the His bundle (recorded on distal bipoles). The figure shows catheter position in an antero-posterior fluoroscopic image, with bipoles TV3-5 indicated by the asterisk. The patient remained free of symptoms, off anti-arrhythmic drugs, to follow-up at 5 months. Ablation of peri-nodal atrial tachycardias can be challenging, with risk of atrio-ventricular block, and mapping of the left atrial septum is advised. Ablation from the non-coronary aortic cusp and the use of cryoablation have also been reported. The use of a T-VAC catheter for this purpose has not been previously described. The full-length version of this report can be viewed at: http://www.escardio.org/communities/EHRA/publications/ep-case-reports/Documents/peri-nodal-atrial-tachycardia-ablation.pdf. Conflict of interest: G.A.N. has received research grants and consultancy fees from Medtronic.