Misleading Long Post-Pacing Interval After Entrainment of Typical Atrial Flutter From the Cavotricuspid Isthmus

• Published in: Journal of the American College of Cardiology Vol. 59; no. 9; pp. 819 - 824
• Main Authors: Vollmann, Dirk, Stevenson, William G., Lüthje, Lars, Sohns, Christian, John, Roy M., Zabel, Markus, Michaud, Gregory F.
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 28.02.2012; Elsevier; Elsevier Limited
• Subjects: Aged; atrial flutter; Atrial Flutter - physiopathology; Atrial Flutter - therapy; Biological and medical sciences; Body Surface Potential Mapping; Cardiac arrhythmia; Cardiac dysrhythmias; Cardiac Pacing, Artificial; Cardiology; Cardiology. Vascular system; Cardiovascular; Cardiovascular disease; Catheter Ablation; Catheters; conduction; entrainment; Female; Follow-Up Studies; Heart; Heart Conduction System - physiopathology; Heart Conduction System - surgery; Heart Rate; Humans; Male; mapping; Medical sciences; Middle Aged; pacing latency; Prospective Studies; Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects); Retrospective Studies; Standard deviation; Tricuspid Valve - physiopathology; Variance analysis; mapping; atrial flutter; entrainment; conduction; AFL; PCL; PPI; CTI; pacing latency; EP; TCL; MAP; tachycardia cycle-length; electrophysiological; post-pacing interval; monophasic action potential; pacing cycle-length; cavotricuspid isthmus; Instrumental stimulation; Arrhythmia; Heart disease; Instrumentation therapy; Cardiovascular disease; Circulatory system; Cardiology; Excitability disorder; Atrial flutter; Interval
• ISSN: 0735-1097; 1558-3597; 1558-3597
• DOI: 10.1016/j.jacc.2011.11.023

The purpose of this study was to evaluate the prevalence and mechanism of a misleading long post-pacing interval (PPI) upon entrainment of typical atrial flutter (AFL) from the cavotricuspid isthmus (CTI). In typical AFL, the PPI from entrainment at the CTI is expected to closely match the tachycardia cycle-length (TCL). Sixty patients with confirmed CTI-dependent AFL were retrospectively analyzed and grouped into short (≤30 ms) or long (>30 ms) PPI-TCL. Thereafter, we prospectively studied 16 patients to acquire the PPI-TCL at 4 CTI sites with entrainment at pacing cycle-lengths (PCLs) 10 to 40 ms shorter than the TCL. Conduction times during AFL and entrainment were compared in 5 segments of the AFL circuit. Eleven patients (18%) in the retrospective analysis had a long PPI-TCL after entrainment from the CTI. Subjects with long PPI-TCL had similar baseline characteristics but greater beat-to-beat TCL variability. In the prospective cohort, PPI-TCL was influenced by the difference between PCL and TCL and site of entrainment. Conduction delays associated with a long PPI-TCL were located predominantly in the segment activated first by the paced orthodromic wave front, and were mainly due to local pacing latency, as confirmed by the use of monophasic action potential catheters. A long PPI upon entrainment of typical AFL from the CTI is common and due to delayed conduction with entrainment. Whether these findings apply to other macro–re-entrant tachycardias warrants further investigation.