Atrial Tachycardia 144 (73%) RA Anatomic Distribution: Total AT - - PowerPoint PPT Presentation

9/7/2012 1

Use of the ECG for localizing atrial tachycardias

Jonathan Kalman Royal Melbourne Hospital Melbourne, Australia (No disclosures)

– 62 (31%) – 22 (11 %) – 16 (8%) – 3 (1.5%) – 3 (1.5%)

144 (73%) RA

– 35 (18%) – 3 (1 %) – 3 (1%) – 3 (2%) – Pul Veins – Lt septum – LAA – CS Body

53 (27%) LA

Atrial Tachycardia Anatomic Distribution

– Crista Terminalis – Para-hisian – CS Os – Septal – RAA

Superior Inferior Posterior Anterior

TV

CS

HBE

MV

AV

Left Fibrous Trigone Right Fibrous Trigone ATach Foci

• ATach Foci

Mitral & Tricuspid Annular Atrial Tachs: Anatomic Distribution

Kistler et al, JACC 2003 Morton et al, JCE 2001

Tricuspid Annulus 38 (19%) Mitral Annulus 8 (4%)

Incessant AT (n)

Anatomic Distribution: Total AT & Incessant AT

Anatomic AT Site 20 40 60 80 100 CT TA/MA PVs

Perinodal LAA/RAA

CS Total AT (n) % Site Incessant 4 22 59 84 18 11 Medi et al, JACC 2009

9/7/2012 2 V1

iso R.Septum Perinodal pos/neg CT

P WAVE ALGORITHM

neg

no yes

V2 – 4 pos

yes no

neg in all inf.leads CT TA TA RAA neg/pos aVL

neg pos

CS os LS NCC iso/pos SMA pos bifid in II &/or V1

yes

LPV LAA RPV sinus P wave

+/-

CT RPV neg in all inf.leads CS body

no pos yes no Kistler, JACC 2006

V1 P wave:

• neg or pos/neg: specificity 100% RA focus
• pos or neg/pos: sensitivity 100% LA focus.

Identify P wave morphology and onset

I II III aVL aVF V1 V2 V3 V5 V6 V4 aVR

Ventricular ectopy/pacing or adenosine to unmask P wave

aVF HBE I V1 Halo-d Halo-p

ABL

V6

Sinus Sinus Atrial Tach

Multipolar mapping to detect activation pattern change

3D Activation Map to localize RA Appendage AT

10 20 30 40 50 60 70

Successful sites Unsuccessful sites Activation time (ms) p=ns

Bipolar activation time (pre P) RAO LAO

9/7/2012 3 A Novel Pacing Maneuver to Localize Focal AT

Mohamed, Klein, JCE 2007

Crista AT vs Other AT

Cristal AT Other AT P

Number

117 (36%) 204 (64%)

Age

57 ± 14 47 ± 20 <0.0001

Female:male

75:25 50:50 <0.0001

Structural Ht Disease

28% 19% 0.05

321 ATs

Heck, HRS 2011 Anatomic Location on Crista Superior 46% Mid 49% Inferior 5%

AT Age distribution

p<0.05 p<0.05

Mode of AT initiation

p=ns

9/7/2012 4 Multiple Focal Atrial Tachycardias

Pt Age Duration (yrs) AT 1 AT 2 AT 3 1 48 12 TA TA 2 60 11 CS os CT 3 63 7 CT R septal TA 4 58 1.5 MA RUPV 5 59 2 CT CS os CS 6 61 8 CS os CT- mid SVC/RA 7 28 16 CS os CT AVNRT 8 59 20 CT-high CT-mid 9 53 0.75 MA CT 10 53 4 CT-mid CT-high

Hillock et al, Heart Rhythm 2007

7/10 CT focus, 4/10 CS os

All female

22 yr old with ATach Superior CT

I aVF V1 V6 II III aVR aVL V2 V3 V4 V5

22 yr old with incessant ATach Superior CT

I V1 V6 CSp CSd CT 1,2 CT 19,20 II HBE

22 yr old with incessant ATach Superior CT

I V1 V6 CSp CSd CT 1,2 CT 19,20 II ABL LAO RAO

• 20ms

CT FO SVC CS Os IVC

9/7/2012 5

Electro-anatomic map

SVC-RA Jn RA LA

RSPV vs. Superior CT

Tc P wave in V1

II I AVR III AVL V1 AVF V6

RSPV RIPV

II I AVR III AVL V1 AVF V6

High CT

AEB SR

RSPV

AEB SR

RSPV SVC Crista RAA Ao

CT: biphasic in V1 or if pos also pos in SR RSPV: positive

Kistler, JACC 2006

31 yr old male: Incessant Tachycardia

I II III aVL aVF V1 V2 V3 V5 V6 V4 aVR

“Bump”

Termination

• f AT in

LSPV

ABL II CS p CS d V1 V6 HBE

Lasso Guided PV Isolation

9/7/2012 6

PV Tachycardia RF Ablation

Induction Spontaneous/Isuprel – 43 (talking/coughing-6) PES/Burst pacing – 0 Recurrence Same location – 7/43 New Focus – 1/43 Long term AF development

2/43 6 ± 4 yrs F/up

Anatomic location Ostial – 41 Within PV - 2 RF Approach Focal – 39 PV Isolation - 4

Kistler Circ 2003, Teh JCE 2010

LIPV

Sensitivity 82% Specificity 98% PPV 88% NPV 97%

LSPV vs LAA AT: P waves

iso or neg in lead I + V1-6 bifid pos in lead II &/or V1

LSPV Tc P wave

LSPV

II I AVR III AVL V1 AVF V6

LAA

Kistler, JACC 2006

I II III aVR aVF aVL V1 V2 V3 V4 V5 V6

24 yr old woman, incessant AT

Abl d Abl p HBE CSd CSp I II V1 V6

24 yr old woman, incessant AT LAA

RF on

LAO RAO

• 55ms

9/7/2012 7

24 yr old ♀, incessant AT anterior base of LAA EP, ECG & RFA of LAA AT

• 13 pts, 7 m, mean age 30 yrs. Sporadic - 5, Incessant /continuous – 8
• 13/13 at base of LAA (11 medial, 2 lateral)
• RFA successful in 13/13 with 11 ± 5 RFs

Yamada, Kay HR 2007

Neg P wave I & aVL (12/13):

Sens 92%, Spec 97% PPV 92%; NPV 97%

18 yr old boy p/w severe CHF, Incessant tachycardia 120 bpm

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

TA

LAO RAO

TA

Figure 2

RA Appendage Tachycardia

9/7/2012 8

RAA Tachycardia – ECG Morphology

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

• V1 /V2

– neg in 10/10 – notching 6/10

• Variable precordial

transition to pos in V6

• II, III, aVF

– Low amplitude pos 9/10

Roberts-Thomson et al, J Cardiovasc Electrophysiol 2007

Focal AT from the RAA

• 10/261(3.8%) pts undergoing RFA for focal AT
• 9 males, mean age 39 years
• Symptoms mean 4.1 years.
• Tachycardia

– incessant 7 pts, spontaneous 1 pt, induced by PES 2 pts

• Tachy-mediated cardiomyopathy – 5 pts (mild 3, severe 2).
• Anatomic location

– Base 8; tip 2

• Successful RFA 10/10(irrigated RF in 8/10; 25-30W);

– No recurrence @ mean f-up of 8 mths

Roberts-Thomson et al, J Cardiovasc Electrophysiol 2007

Characterization of focal right atrial appendage tachycardia

• 15/186 (8%) pts undergoing RFA for AT
• Tip of RAA - 9 pts (60%), base of RAA - 6 pts (40%)
• 5 /15 pts irrigated RF
• RAAT pts vs other AT pts

– ↑ male (66% vs. 38%; p = 0.013) – younger (32 yrs vs. 55 yrs; p = 0.001) – ↑incessant tachycardia (53% vs. 16%; p = 0.001) – LV dysfunction (27 % vs. 5%; ps = 0.018). – RFA effective in all pts (100 vs. 75%; p = 0.022) – No recurrences (0 vs. 8%) mean f-up 37 months.

Freixa, J.Brugada. Europace 2008

22 yr old male incessant RAA AT: Unsuccessful ablation (3rd attempt)

(irrigated RF to 35W)

9/7/2012 9

SVC TA CT RAA IVC

Anatomy RAA

• viewed

from posterior

SUP TA RAA II I AVR III AVL V1 AVF V6

TV

CS

HBE

• Superior Tricuspid Annulus vs RAA

RAA

• ECG appearance similar
• V1

– neg in 100% – notching 60%

• Late transition to pos in V6
• II, III, aVF

– Low amplitude pos 90%

Kistler, JACC 2006

• /+ or iso/+ in V1

neg in II, III, aVF + aVL

CS os vs. Rt Perinodal vs. Lt Septal

CS os

I II III aVL aVF V1 V6 aVR

Left Septal Right perinodal

CS Os Tc P wave ECG of Focal AT from Non-Coronary Aortic Sinus

• Lead I & aVL

– pos 9/9

• V1 & V2

– neg/pos 9/9

• II, III, & aVF

– neg/pos in 7/9 – neg in 1/9 – pos in 1/9

Ouyang et al, JACC 2006

9/7/2012 10

52 yr woman p/w paroxysmal AT

I II III aVL aVF V1 V2 V3 V6 V4 aVR

Peri-nodal ATach: Successful RF Site

II CS p CS d V1 HBE I ABL V6

• 58ms to P wave

67 yr woman 10 yr Hx SVT

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

II CS p CS d V1 HBE

I

Onset of AT with VAAV response

9/7/2012 11 NCC: -15 Rt perinodal: -25 Lt septal: -30

II CS p CS d V1 HBE

I

ABL V6 Rt Peri-nodal

Mapping “left septal” AT

NC aortic sinus Lt Peri-nodal

41 yr male 5 yr Hx SVT

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

NCC: -15 Rt perinodal: -30 Lt septal: -20

II CS p CS d V1 HBE

I

ABL V6

9/7/2012 12 EP properties of para-Hisian AT

• 38 pts (mean age 63yrs; 23 female)
• Origin anteroseptal TA
• Narrow P wave
• Adenosine termination 34/35 pts.
• RFA attempt 30/38 pts(79%); successful 26/30(87%)
• Access from NC aortic sinus in 4 pts
• CONCLUSIONS:
• Properties consistent with AT from TA, MA
• Should be considered a subset of “annular” ATs.
• Mechanism c/w cAMP-mediated triggered activity.

Iwai, Lerman. Heart Rhythm 2011

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Mitral Annular Tachycardia: P Wave Morphology

LAO MAP CS

HBE

CT Sensitivity 88% Specificity 99%

• /+ in V1

iso or - aVL

Tc P wave

Abl His CS

LV RV Ao LA

*

MV

Ao MA * LAA LSPV RSPV

Mitral annular AT

Teh HR 2010

Mapping and Ablation of AT

• Anatomy/Anatomic distribution
• P wave useful

– (normal anatomy/no prior AF ablation)

• Locations in close anatomic proximity
• Range of mapping tools

9/7/2012 13 Recovery of tach-mediated cardiomyopathy post RFA

• Return to normal in 29/30 pts at mean 2.8 mths
• No recurrence of LV dysfunction or late arrhythmias at 20 mths f/up

35% 56%

Medi et al, JACC 2009

Pre-ablation Late post-ablation Controls (n=20) AT-NEF (n=15) AT-LEF (n=18) P value Age, years 47±4 52±4 45±5 0.7 Male, n (%) 13 (65) 5 (53) 12 (71) 0.7 Rest HR,bpm 64±2 67±3 65±2 0.7 eGFR, ml/min 97±3 94±3 103±5 0.2 BMI, kg/m2 24±1 25±1 25±1 0.4 Mths post-RF

• 75±7

59±11 1

Does LV function recover completely after TCM?

Ling, Heart Rhythm Boston 2012 Controls (n=20) AT-NEF (n=15) AT-LEF (n=18) P value LV EDVI, ml/m2 84±3 85±4 102±5* <0.05 LV ESVI, ml/m2 31±2 30±2 41±3* <0.01 LV mass I, g/m2 56±3 54±5 56±5 0.9 LA area (4C), cm2 21±1 22±1 22±1 0.9

MRI – LV morphology

Ling, Heart Rhythm Boston 2012

9/7/2012 14

Controls (n=20) AT-NEF (n=15) AT-LEF (n=18) P value LV EDD, cm 4.8±0.1 4.7±0.2 5.2±0.1 <0.05 LV ESD, cm 3.1±0.1 2.9±0.1 3.6±0.1 <0.01 IVST, cm 0.9±0.0 0.9±0.1 0.9±0.0 0.7 PWT, cm 0.8±0.0 0.9±0.0 0.9±0.0 0.7 LV mass I, g/m2 82±3 82±5 85±4 0.9 LA diameter, cm 3.4±0.1 3.6±0.5 3.6±0.1 0.4

Echocardiography - LV morphology

Ling, Heart Rhythm Boston 2012 Controls (n=20) AT-NEF (n=15) AT-LEF (n=18) P value Systolic fn LV EF, % 66±1 66±1 60±2*† <0.01 FS, % 36±1 41±1 32±2*† <0.01 Diastolic fn Mitral E vel, cm/s 0.7±0.0 0.7±0.0 0.7±0.1 0.2 Mitral A vel, cm/s 0.6±0.0 0.6±0.0 0.5±0.0 0.5 E/A ratio 1.4±0.1 1.5±0.1 1.5±01 0.9 Mitral E wave DT, ms 193±9 199±13 206±9 0.6 Mean E/e’ ratio 7.6±0.5 7.8±0.4 7.0±0.5 0.6

Echocardiography - LV function

Ling, Heart Rhythm Boston 2012 Controls (n=20) AT-NEF (n=15) AT-LEF (n=18) P value Regional fibrosis Delayed Enhance, n (%) 1 Diffuse fibrosis LV T1 time – basal, ms 510±21 503±20 498±13 0.5 LV T1 time – mid, ms 565±23 543±39 503±18 0.3 LV T1 time – apex, ms 594±21 535±39 517±30 0.1 LV T1 time - global ms 556±14 529±23 496±15* <0.05

MRI – LV fibrosis

Ling, Heart Rhythm Boston 2012

9/7/2012 15 28 yr woman with atrial tachycardia: Origin Left septum

I II III aVL aVF V1 V2 V3 V5 V6 V4 aVR

9/7/2012 1

Use of the ECG for localizing atrial tachycardias

Jonathan Kalman Royal Melbourne Hospital Melbourne, Australia (No disclosures)

– 62 (31%) – 22 (11 %) – 16 (8%) – 3 (1.5%) – 3 (1.5%)

144 (73%) RA

– 35 (18%) – 3 (1 %) – 3 (1%) – 3 (2%) – Pul Veins – Lt septum – LAA – CS Body

53 (27%) LA

Atrial Tachycardia Anatomic Distribution

– Crista Terminalis – Para-hisian – CS Os – Septal – RAA

Superior Inferior Posterior Anterior

TV

CS

HBE

MV

AV

Left Fibrous Trigone Right Fibrous Trigone ATach Foci

• ATach Foci

Mitral & Tricuspid Annular Atrial Tachs: Anatomic Distribution

Kistler et al, JACC 2003 Morton et al, JCE 2001

Tricuspid Annulus 38 (19%) Mitral Annulus 8 (4%)

Incessant AT (n)

Anatomic Distribution: Total AT & Incessant AT

Anatomic AT Site 20 40 60 80 100 CT TA/MA PVs

Perinodal LAA/RAA

CS Total AT (n) % Site Incessant 4 22 59 84 18 11 Medi et al, JACC 2009

9/7/2012 2 V1

iso R.Septum Perinodal pos/neg CT

P WAVE ALGORITHM

neg

no yes

V2 – 4 pos

yes no

neg in all inf.leads CT TA TA RAA neg/pos aVL

neg pos

CS os LS NCC iso/pos SMA pos bifid in II &/or V1

yes

LPV LAA RPV sinus P wave

+/-

CT RPV neg in all inf.leads CS body

no pos yes no Kistler, JACC 2006

V1 P wave:

• neg or pos/neg: specificity 100% RA focus
• pos or neg/pos: sensitivity 100% LA focus.

Identify P wave morphology and onset

I II III aVL aVF V1 V2 V3 V5 V6 V4 aVR

Ventricular ectopy/pacing or adenosine to unmask P wave

aVF HBE I V1 Halo-d Halo-p

ABL

V6

Sinus Sinus Atrial Tach

Multipolar mapping to detect activation pattern change

3D Activation Map to localize RA Appendage AT

10 20 30 40 50 60 70

Successful sites Unsuccessful sites Activation time (ms) p=ns

Bipolar activation time (pre P) RAO LAO

9/7/2012 3 A Novel Pacing Maneuver to Localize Focal AT

Mohamed, Klein, JCE 2007

Crista AT vs Other AT

Cristal AT Other AT P

Number

117 (36%) 204 (64%)

Age

57 ± 14 47 ± 20 <0.0001

Female:male

75:25 50:50 <0.0001

Structural Ht Disease

28% 19% 0.05

321 ATs

Heck, HRS 2011 Anatomic Location on Crista Superior 46% Mid 49% Inferior 5%

AT Age distribution

p<0.05 p<0.05

Mode of AT initiation

p=ns

9/7/2012 4 Multiple Focal Atrial Tachycardias

Pt Age Duration (yrs) AT 1 AT 2 AT 3 1 48 12 TA TA 2 60 11 CS os CT 3 63 7 CT R septal TA 4 58 1.5 MA RUPV 5 59 2 CT CS os CS 6 61 8 CS os CT- mid SVC/RA 7 28 16 CS os CT AVNRT 8 59 20 CT-high CT-mid 9 53 0.75 MA CT 10 53 4 CT-mid CT-high

Hillock et al, Heart Rhythm 2007

7/10 CT focus, 4/10 CS os

All female

22 yr old with ATach Superior CT

I aVF V1 V6 II III aVR aVL V2 V3 V4 V5

22 yr old with incessant ATach Superior CT

I V1 V6 CSp CSd CT 1,2 CT 19,20 II HBE

22 yr old with incessant ATach Superior CT

I V1 V6 CSp CSd CT 1,2 CT 19,20 II ABL LAO RAO

• 20ms

CT FO SVC CS Os IVC

9/7/2012 5

Electro-anatomic map

SVC-RA Jn RA LA

RSPV vs. Superior CT

Tc P wave in V1

II I AVR III AVL V1 AVF V6

RSPV RIPV

II I AVR III AVL V1 AVF V6

High CT

AEB SR

RSPV

AEB SR

RSPV SVC Crista RAA Ao

CT: biphasic in V1 or if pos also pos in SR RSPV: positive

Kistler, JACC 2006

31 yr old male: Incessant Tachycardia

I II III aVL aVF V1 V2 V3 V5 V6 V4 aVR

“Bump”

Termination

• f AT in

LSPV

ABL II CS p CS d V1 V6 HBE

Lasso Guided PV Isolation

9/7/2012 6

PV Tachycardia RF Ablation

Induction Spontaneous/Isuprel – 43 (talking/coughing-6) PES/Burst pacing – 0 Recurrence Same location – 7/43 New Focus – 1/43 Long term AF development

2/43 6 ± 4 yrs F/up

Anatomic location Ostial – 41 Within PV - 2 RF Approach Focal – 39 PV Isolation - 4

Kistler Circ 2003, Teh JCE 2010

LIPV

Sensitivity 82% Specificity 98% PPV 88% NPV 97%

LSPV vs LAA AT: P waves

iso or neg in lead I + V1-6 bifid pos in lead II &/or V1

LSPV Tc P wave

LSPV

II I AVR III AVL V1 AVF V6

LAA

Kistler, JACC 2006

I II III aVR aVF aVL V1 V2 V3 V4 V5 V6

24 yr old woman, incessant AT

Abl d Abl p HBE CSd CSp I II V1 V6

24 yr old woman, incessant AT LAA

RF on

LAO RAO

• 55ms

9/7/2012 7

24 yr old ♀, incessant AT anterior base of LAA EP, ECG & RFA of LAA AT

• 13 pts, 7 m, mean age 30 yrs. Sporadic - 5, Incessant /continuous – 8
• 13/13 at base of LAA (11 medial, 2 lateral)
• RFA successful in 13/13 with 11 ± 5 RFs

Yamada, Kay HR 2007

Neg P wave I & aVL (12/13):

Sens 92%, Spec 97% PPV 92%; NPV 97%

18 yr old boy p/w severe CHF, Incessant tachycardia 120 bpm

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

TA

LAO RAO

TA

Figure 2

RA Appendage Tachycardia

9/7/2012 8

RAA Tachycardia – ECG Morphology

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

• V1 /V2

– neg in 10/10 – notching 6/10

• Variable precordial

transition to pos in V6

• II, III, aVF

– Low amplitude pos 9/10

Roberts-Thomson et al, J Cardiovasc Electrophysiol 2007

Focal AT from the RAA

• 10/261(3.8%) pts undergoing RFA for focal AT
• 9 males, mean age 39 years
• Symptoms mean 4.1 years.
• Tachycardia

– incessant 7 pts, spontaneous 1 pt, induced by PES 2 pts

• Tachy-mediated cardiomyopathy – 5 pts (mild 3, severe 2).
• Anatomic location

– Base 8; tip 2

• Successful RFA 10/10(irrigated RF in 8/10; 25-30W);

– No recurrence @ mean f-up of 8 mths

Roberts-Thomson et al, J Cardiovasc Electrophysiol 2007

Characterization of focal right atrial appendage tachycardia

• 15/186 (8%) pts undergoing RFA for AT
• Tip of RAA - 9 pts (60%), base of RAA - 6 pts (40%)
• 5 /15 pts irrigated RF
• RAAT pts vs other AT pts

– ↑ male (66% vs. 38%; p = 0.013) – younger (32 yrs vs. 55 yrs; p = 0.001) – ↑incessant tachycardia (53% vs. 16%; p = 0.001) – LV dysfunction (27 % vs. 5%; ps = 0.018). – RFA effective in all pts (100 vs. 75%; p = 0.022) – No recurrences (0 vs. 8%) mean f-up 37 months.

Freixa, J.Brugada. Europace 2008

22 yr old male incessant RAA AT: Unsuccessful ablation (3rd attempt)

(irrigated RF to 35W)

9/7/2012 9

SVC TA CT RAA IVC

Anatomy RAA

• viewed

from posterior

SUP TA RAA II I AVR III AVL V1 AVF V6

TV

CS

HBE

• Superior Tricuspid Annulus vs RAA

RAA

• ECG appearance similar
• V1

– neg in 100% – notching 60%

• Late transition to pos in V6
• II, III, aVF

– Low amplitude pos 90%

Kistler, JACC 2006

• /+ or iso/+ in V1

neg in II, III, aVF + aVL

CS os vs. Rt Perinodal vs. Lt Septal

CS os

I II III aVL aVF V1 V6 aVR

Left Septal Right perinodal

CS Os Tc P wave ECG of Focal AT from Non-Coronary Aortic Sinus

• Lead I & aVL

– pos 9/9

• V1 & V2

– neg/pos 9/9

• II, III, & aVF

– neg/pos in 7/9 – neg in 1/9 – pos in 1/9

Ouyang et al, JACC 2006

9/7/2012 10

52 yr woman p/w paroxysmal AT

I II III aVL aVF V1 V2 V3 V6 V4 aVR

Peri-nodal ATach: Successful RF Site

II CS p CS d V1 HBE I ABL V6

• 58ms to P wave

67 yr woman 10 yr Hx SVT

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

II CS p CS d V1 HBE

I

Onset of AT with VAAV response

9/7/2012 11 NCC: -15 Rt perinodal: -25 Lt septal: -30

II CS p CS d V1 HBE

I

ABL V6 Rt Peri-nodal

Mapping “left septal” AT

NC aortic sinus Lt Peri-nodal

41 yr male 5 yr Hx SVT

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

NCC: -15 Rt perinodal: -30 Lt septal: -20

II CS p CS d V1 HBE

I

ABL V6

9/7/2012 12 EP properties of para-Hisian AT

• 38 pts (mean age 63yrs; 23 female)
• Origin anteroseptal TA
• Narrow P wave
• Adenosine termination 34/35 pts.
• RFA attempt 30/38 pts(79%); successful 26/30(87%)
• Access from NC aortic sinus in 4 pts
• CONCLUSIONS:
• Properties consistent with AT from TA, MA
• Should be considered a subset of “annular” ATs.
• Mechanism c/w cAMP-mediated triggered activity.

Iwai, Lerman. Heart Rhythm 2011

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Mitral Annular Tachycardia: P Wave Morphology

LAO MAP CS

HBE

CT Sensitivity 88% Specificity 99%

• /+ in V1

iso or - aVL

Tc P wave

Abl His CS

LV RV Ao LA

*

MV

Ao MA * LAA LSPV RSPV

Mitral annular AT

Teh HR 2010

Mapping and Ablation of AT

• Anatomy/Anatomic distribution
• P wave useful

– (normal anatomy/no prior AF ablation)

• Locations in close anatomic proximity
• Range of mapping tools

9/7/2012 13 Recovery of tach-mediated cardiomyopathy post RFA

• Return to normal in 29/30 pts at mean 2.8 mths
• No recurrence of LV dysfunction or late arrhythmias at 20 mths f/up

35% 56%

Medi et al, JACC 2009

Pre-ablation Late post-ablation Controls (n=20) AT-NEF (n=15) AT-LEF (n=18) P value Age, years 47±4 52±4 45±5 0.7 Male, n (%) 13 (65) 5 (53) 12 (71) 0.7 Rest HR,bpm 64±2 67±3 65±2 0.7 eGFR, ml/min 97±3 94±3 103±5 0.2 BMI, kg/m2 24±1 25±1 25±1 0.4 Mths post-RF

• 75±7

59±11 1

Does LV function recover completely after TCM?

Ling, Heart Rhythm Boston 2012 Controls (n=20) AT-NEF (n=15) AT-LEF (n=18) P value LV EDVI, ml/m2 84±3 85±4 102±5* <0.05 LV ESVI, ml/m2 31±2 30±2 41±3* <0.01 LV mass I, g/m2 56±3 54±5 56±5 0.9 LA area (4C), cm2 21±1 22±1 22±1 0.9

MRI – LV morphology

Ling, Heart Rhythm Boston 2012

9/7/2012 14

Controls (n=20) AT-NEF (n=15) AT-LEF (n=18) P value LV EDD, cm 4.8±0.1 4.7±0.2 5.2±0.1 <0.05 LV ESD, cm 3.1±0.1 2.9±0.1 3.6±0.1 <0.01 IVST, cm 0.9±0.0 0.9±0.1 0.9±0.0 0.7 PWT, cm 0.8±0.0 0.9±0.0 0.9±0.0 0.7 LV mass I, g/m2 82±3 82±5 85±4 0.9 LA diameter, cm 3.4±0.1 3.6±0.5 3.6±0.1 0.4

Echocardiography - LV morphology

Ling, Heart Rhythm Boston 2012 Controls (n=20) AT-NEF (n=15) AT-LEF (n=18) P value Systolic fn LV EF, % 66±1 66±1 60±2*† <0.01 FS, % 36±1 41±1 32±2*† <0.01 Diastolic fn Mitral E vel, cm/s 0.7±0.0 0.7±0.0 0.7±0.1 0.2 Mitral A vel, cm/s 0.6±0.0 0.6±0.0 0.5±0.0 0.5 E/A ratio 1.4±0.1 1.5±0.1 1.5±01 0.9 Mitral E wave DT, ms 193±9 199±13 206±9 0.6 Mean E/e’ ratio 7.6±0.5 7.8±0.4 7.0±0.5 0.6

Echocardiography - LV function

Ling, Heart Rhythm Boston 2012 Controls (n=20) AT-NEF (n=15) AT-LEF (n=18) P value Regional fibrosis Delayed Enhance, n (%) 1 Diffuse fibrosis LV T1 time – basal, ms 510±21 503±20 498±13 0.5 LV T1 time – mid, ms 565±23 543±39 503±18 0.3 LV T1 time – apex, ms 594±21 535±39 517±30 0.1 LV T1 time - global ms 556±14 529±23 496±15* <0.05

MRI – LV fibrosis

Ling, Heart Rhythm Boston 2012

9/7/2012 15 28 yr woman with atrial tachycardia: Origin Left septum

I II III aVL aVF V1 V2 V3 V5 V6 V4 aVR