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Kirchhof, P. et al.

Paulus Kirchhof, Murat Ozgün, Stephan Zellerhoff, Gerold Mönnig, Lars Eckardt, Kristina Wasmer, Walter Heindel, Günter Breithardt, David Maintz,

Diastolic isthmus length and 'vertical' isthmus angulation identify patients with difficult catheter ablation of typical atrial flutter: a pre-procedural MRI study.

AIMS: Catheter ablation of isthmus-dependent atrial flutter is technically demanding in some patients and extremely simple in others. The intervention targets a defined anatomical structure, the so-called cavotricuspid isthmus (CTI). We sought to characterize CTI anatomy in vivo in patients with difficult and simple catheter ablation of atrial flutter. METHODS AND RESULTS: Twenty-six patients were studied. Seven patients with difficult (n = 6) or extremely simple (n = 1) CTI ablation procedures were retrospectively selected from our catheter ablation database. Thereafter, we prospectively studied 19 patients undergoing CTI ablation in our department. We visualized CTI anatomy by ECG- and respiration-gated free precession 1.5 T cardiac magnetic resonance imaging (MRI). Magnetic resonance imaging was analysed for systolic and diastolic CTI length, the angle between the vena cava inferior and CTI, and pouch-like recesses. These parameters were compared between patients with difficult and simple procedures, split by the median number of energy applications. Patients with difficult procedures had a longer diastolic CTI length (diastolic isthmus length 20.3 +/- 1.8 mm) than those with simple procedures (diastolic isthmus length 16.6 +/- 1.7 mm, all data as mean +/- SEM, P < 0.05). Cavotricuspid isthmus angulation with respect to inferior vena cava was closer to 90 degrees in patients with difficult procedures (deviation from 90 degrees: 15 +/- 2 degrees) than those with simple procedures (deviation 23 +/- 4 degrees, P < 0.05). Systolic CTI length was not different between groups (32 +/- 2 mm in both groups, P > 0.2). CONCLUSION: Longer diastolic, but not systolic, CTI length and a rectangular angle between CTI and inferior vena cava render CTI catheter ablation difficult. Visualization of isthmus anatomy may help to guide difficult CTI ablation procedures.[1]

References

Diastolic isthmus length and 'vertical' isthmus angulation identify patients with difficult catheter ablation of typical atrial flutter: a pre-procedural MRI study. Kirchhof, P., Ozgün, M., Zellerhoff, S., Mönnig, G., Eckardt, L., Wasmer, K., Heindel, W., Breithardt, G., Maintz, D. Europace (2009) [Pubmed]

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