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Peri-mitral atrial tachycardia using the marshall bundle epicardial connection

Session Clinical case corner 3

Speaker Kanae Hasegawa

Congress : EHRA 2019

  • Topic : arrhythmias and device therapy
  • Sub-topic : Arrhythmias, General - Clinical
  • Session type : Poster Session
  • FP Number : P1572

Authors : K Hasegawa (Fukui,JP), S Miyazaki (Fukui,JP), S Miyazaki (Fukui,JP), S Miyazaki (Fukui,JP), K Kaseno (Fukui,JP), K Kaseno (Fukui,JP), K Kaseno (Fukui,JP), H Tada (Fukui,JP), H Tada (Fukui,JP), H Tada (Fukui,JP)

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Authors:
K Hasegawa1 , S Miyazaki1 , S Miyazaki1 , S Miyazaki1 , K Kaseno1 , K Kaseno1 , K Kaseno1 , H Tada1 , H Tada1 , H Tada1 , 1University of Fukui, Cardiology - Fukui - Japan ,

Citation:

A 89-year-old woman with dilated cardiomyopathy underwent a second ablation procedure for persistent atrial tachycardia (AT) with repeated worsening of heart failure due to the tachycardia.  She had undergone pulmonary vein (PV) isolation by cryoballoon, cavo-tricuspid isthmus, left atrial (LA) roof line, and mitral isthmus linear ablation for symptomatic and drug-resistant persistent atrial fibrillation (AF) in the first procedure 3 months earlier.  The starting rhythm in the second procedure was a stable AT with a tachycardia cycle length of 540 ms.  No PVs reconnected and the block of LA roof and mitral isthmus lines remained.  For detailed analysis of epicardial connection, 2 multipolar catheters were placed at distal and proximal coronary sinus from carotid and femoral veins, respectively.  Moreover, an additional 2 Fr hexapolar catheter (EP star, Japan Life Line, Tokyo, Japan) was inserted into vein of Marshall (VOM).  Activation mapping using high-resolution 3-dimensional mapping system (Rhythmia, Boston Scientific, Natick, Massachusetts) revealed the both endocardial and epicardial conduction block along the mitral isthmus, and peri-mitral AT in which Marshall bundle (MB) epicardial connection bypassed the scar area (Fig A).  Entrainment mapping showed that post-pacing interval from the catheter inside the VOM was equal to the tachycardia cycle length, which further confirmed the diagnosis (Fig A).  A 4.8 seconds of an application at the slow conduction area (the connection between LA ridge and distal MB) terminated the AT (Fig A and B).  Bi-directional conduction block of MB-LA connections were confirmed, and any ATs were not inducible.  No AT recurrence has been observed for 3 months.



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