A Case Report of Uncommon Atrial Flutter (AFL) with Coexistence of Sick Sinus Syndrome and Atrioventricular Conduction Disturbance Who Underwent Radiofrequency Catheter Ablation and Pacemaker Implantation

A 82-year-old male who had near syncope was admitted to our hospital. His heart rate monitoring had been demonstrating uncommon AFL with heart rate 30–45/minute (F-F interval: 210 milliseconds) because of atrioventricular conduction disturbance. Activation map recorded by the CARTO system during tachycardia showed reverse common AFL. We confirmed that the circuit of AFL existed in tricuspid valve annulus by post pacing interval mapping. We could also induce common AFL. We performed linear ablation at anatomical isthmus between tricuspid annulus and inferior vena cava by radiofrequency catheter ablation during AFL, which resulted in termination. We confirmed bidirectional conduction block at anatomical isthmus after the procedure. Atrial fibrillation (AF) instead of AFL was induced by burst pacing, which could not be terminated by 70 mg of Pilsicainide injection. Sinus arrest for five seconds was recorded just after the DC therapy for AF, although sinus node recovery time was within normal limits without any anti-arrhythmic drugs. We diagnosed so-called binodal disease, which became clinically evident by Pilsicainide. It is suggested that we had better pay attention to binodal disease when we encounter the atrioventricular conduction disturbance.