New Insights Into an Old Arrhythmia

Using high-resolution 3-dimensional (3D) mapping, the aim of this study was to further characterize right atrial macro-re-entrant tachycardias and answer unresolved questions in the understanding of this arrhythmia.Despite advances in understanding of the mechanisms of right atrial macro-re-entrant tachycardias, many questions lack definitive answers. The advent of high-resolution 3D mapping provides an opportunity to gain further insights into the nature of these common circuits.A total of 25 patients with right atrial macro-re-entrant tachycardia were studied. High-resolution 3D mapping (Rhythmia mapping system, Boston Scientific, Natick, Massachusetts) was performed. Regional voltage and conduction velocity were determined. Maps were analyzed to characterize wave front propagation patterns in all atrial regions. The relationship between substrate and conduction was evaluated.A total of 42 right atrial macro-re-entrant circuits were observed. The most common location of the posterior line of block was the posteromedial right atrium (73%). This line of block continued superiorly into the superior vena cava, taking an oblique course to finish on the anterior superior vena cava aspect in 73%. Conduction delay at the crista terminalis was less common (23%). Conduction slowing or block was seen at the limbus of the fossa ovalis (73%) and Eustachian ridge (77%). Highly variable and localized areas of slow conduction were also observed in the inferior septum (45%), superior septum (27%), anterosuperior right atrium (23%), and lateral right atrium (23%). Localized conduction slowing was seen in the cavotricuspid isthmus in 50% of patients, but there was no generalized conduction slowing in this isthmus. The voltage in regions of slow conduction was significantly lower compared with areas of normal conduction velocity (p < 0.001). Conduction channels were observed in 55% of patients.High-resolution 3D mapping has provided new insights into the nature of right atrial macro-re-entrant tachycardias. Variable regions of abnormal atrial substrate were associated with conduction slowing and block. Individual variation in propagation patterns was observed in association with this variable substrate. (Mapping of Atrial Arrhythmias Using High Spatial Resolution Mapping Catheters and the Rhythmia Mapping System; ACTRN12615000544572).