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Epicardial Ablation of Refractory Focal Atrial Tachycardia After a Failed Endocardial Approach

Published:November 18, 2022DOI:https://doi.org/10.1016/j.hrthm.2022.11.007

      Background

      Endocardial ablation is effective for most focal atrial tachycardias (FATs). In rare circumstances, the FAT can originate from the epicardial side of atrium.

      OBJECTIVE

      In the present study, we retrospectively assessed the percutaneous approach for epicardial ablation of FAT when standard endocardial ablation had failed.

      METHODS

      Among a consecutive 186 patients undergoing ablation for 198 FATs, epicardial mapping and ablation via a percutaneous subxiphoid approach were attempted in ten patients due to failed endocardial ablation.

      RESULTS

      In three cases, the origin of FAT was at the epicardial side of the junction of the right atrial appendage (RAA) and superior vena cava (SVC). In three cases, the origin of FAT was located in the epicardial region of the LA insertion of Bachmann’s bundle (BB). In two cases, the FAT originated from the epicardial side of right atrial free wall. In one case, the FAT was successfully ablated from the epicardial side of the RAA, and in the remaining case, the origin of FAT was located in the epicardial region of the vein of Marshall (VOM). All FATs were successfully eliminated by ablation at the epicardial earliest activation site (EAS).

      CONCLUSIONS

      Epicardial mapping and ablation can be considered as an effective and safe option for FAT resistant to endocardial ablation.

      KEYWORDS

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      References:

        • Lesh M.D.
        • Van Hare G.F.
        • Epstein L.M.
        • et al.
        Radiofrequency catheter ablation of atrial arrhythmias: results and mechanisms.
        Circulation. 1994; 89: 1074-1089
        • Saoudi N.
        • Cosio F.
        • Waldo A.
        • et al.
        Classifification of atrial flutter and regular atrial tachycardia according to electrophysiologic mechanism and anatomic bases: a statement from a joint expert group from the Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology.
        J Cardiovasc Electrophysiol. 2001; 12: 852-866
        • Sosa E.
        • Scanavacca M.
        • d'Avila A.
        • Pilleggi F.
        A new technique to perform epicardial mapping in the electrophysiology laboratory.
        J Cardiovasc Electrophysiol. 1996; 7: 531-536
        • Yamada T.
        • McElderry H.T.
        • Allison J.S.
        • Kay G.N.
        Focal atrial tachycardia originating from the epicardial left atrial appendage.
        Heart Rhythm. 2008; 5: 766-767
        • Phillips K.P.
        • Natale A.
        • Sterba R.
        • et al.
        Percutaneous pericardial instrumentation for catheter ablation of focal atrial tachycardias arising from the left atrial appendage.
        J Cardiovasc Electrophysiol. 2008; 19: 430-433
      1. Yamamoto T, Iwasaki YK, Fujimoto Y,et al. The characteristics and efficacy of catheter ablation of focal atrial tachycardia arising from an epicardial site.Clin Cardiol. 2021;44:563-572.

        • Jacobson J.T.
        • Kraus A.
        • Lee R.
        • Goldberger J.J.
        Epicardial/endocardial sinus node ablation after failed endocardial ablation for the treatment of inappropriate sinus tachycardia.
        J Cardiovasc Electrophysiol. 2014; 25: 236-241
        • Sanchez-Quintana D.
        • Anderson R.H.
        • Cabrera J.A.
        • et al.
        The terminal crest: morphological features relevant to electrophysiology.
        Heart. 2002; 88: 406-411
      2. Ueda A, McCarthy KP, Sánchez-Quintana D, Ho SY. Right atrial appendage and vestibule: further anatomical insights with implications for invasive electrophysiology.

        • Ho S.Y.
        • Sanchez-Quintana D.
        • Cabrera J.A.
        • Anderson R.H.
        Anatomy of the left atrium: implications for radiofrequency ablation of atrial fibrillation.
        J Cardiovasc Electrophysiol. 1999; 10: 1525-1533
        • Su_arez A.G.
        • Hornero F.
        • Berjano E.J.
        Mathematical modeling of epicardial RF ablation of atrial tissue with overlying epicardial fat.
        Open Biomed Eng J. 2010; 4: 47-55
        • Chen S.A.
        • Chiang C.E.
        • Yang C.J.
        • et al.
        Sustained atrial tachycardia in adult patients: electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation.
        Circulation. 1994; 90: 1262-1278
        • Yamashita S.
        • Hooks D.A.
        • Cheniti G.
        • Jais P.
        High-density contact and noninvasive mapping of focal atrial tachycardia: evidence of dual endocardial exits from an epicardial focus.
        Pacing Clin Electrophysiol. 2018; 41: 666-668