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Characteristics of Macroreentries Using an Epicardial Bypass: Pseudo-Focal Atrial Tachycardia Case Series
  • +19
  • Yosuke Nakatani,
  • Takashi Nakashima ,
  • Josselin Duchateau,
  • Konstantinos Vlachos,
  • Philipp Krisai,
  • Takamitsu Takagi,
  • Tsukasa Kamakura,
  • Clémentine André,
  • Cyril Goujeau,
  • F. Daniel Ramirez,
  • Remi Chauvel,
  • Romain Tixier,
  • Masateru Takigawa,
  • Takeshi Kitamura,
  • Ghassen Cheniti,
  • Arnaud Denis,
  • Frederic Sacher,
  • Mélèze Hocini,
  • Michel Haissaguerre,
  • Pierre Jais,
  • Nicolas Derval,
  • Thomas Pambrun
Yosuke Nakatani
University of Toyama
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Takashi Nakashima
1. Electrophysiology and Ablation Unit and L’Institut de rythmologie et modélisation cardiaque (LIRYC)
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Josselin Duchateau
Centre Hospitalier Universitaire de Bordeaux
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Konstantinos Vlachos
Evangelismos General Hospital of Athens
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Philipp Krisai
University of Bordeaux
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Takamitsu Takagi
Hôpital Cardiologique du Haut- Lévêque, CHU Bordeaux, L’Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux
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Tsukasa Kamakura
National Cerebral and Cardiovascular Center
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Clémentine André
CHU Trousseau
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Cyril Goujeau
, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux)
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F. Daniel Ramirez
Centre Hospitalier Universitaire de Bordeaux Hopital Cardiologique
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Remi Chauvel
Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux)
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Romain Tixier
Centre Hospitalier Universitaire de Bordeaux
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Masateru Takigawa
Yokosuka Kyosai Hospital
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Takeshi Kitamura
IHU LIRYC, University of Bordeaux, CHU de Bordeaux
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Ghassen Cheniti
Hôpital Cardiologique du Haut Lévêque
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Arnaud Denis
CHU Bordeaux
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Frederic Sacher
Bordeaux University Hospital
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Mélèze Hocini
Hôpital Cardiologique du Haut-Lévèque
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Michel Haissaguerre
Hopital Cardiologique du Haut-Leveque
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Pierre Jais
Centre Hospitalier Universitaire de Bordeaux
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Nicolas Derval
Hopital cardiologique du haut-leveque
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Thomas Pambrun
Hopital du Haut Leveque/LIRYC, Bordeaux
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Abstract

Introduction: Human atria comprise distinct epicardial layers, which can bypass endocardial layers and lead to downstream centrifugal propagation at the “epi-endo” connection. We sought to characterize anatomical substrates, electrophysiological properties, and ablation outcomes of “pseudo-focal” atrial tachycardias (ATs), defined as macroreentrant ATs mimicking focal ATs. Methods and Results: We retrospectively analyzed ATs showing centrifugal propagation with post-pacing intervals (PPIs) after entrainment pacing suggestive of a macroreentry. A total of 26 patients had pseudo-focal ATs consisting of 15 perimitral, 7 roof-dependent, and 5 cavotricuspid isthmus (CTI)-dependent flutters. A low-voltage area was consistently found at the collision site and co-localized with epicardial layers like the: (1) coronary sinus-great cardiac vein bundle (22%); (2) vein of Marshall bundle (15%); (3) Bachmann bundle (22%); (4) septopulmonary bundle (15%); (5) fossa ovalis (7%); and (6) low right atrium (19%). The mean missing tachycardia cycle length (TCL) was 67 ± 29 ms (22%) on the endocardial activation map. PPI was 9 [0-15] ms and 10 [0-20] ms longer than TCL at the breakthrough site and the opposite site, respectively. While feasible in 25 pseudo-focal ATs (93%), termination was better achieved by blocking the anatomical isthmus than ablating the breakthrough site [24/26 (92%) vs. 1/6 (17%); p < 0.001]. Conclusion: Perimitral, roof-dependent, and CTI-dependent flutters with centrifugal propagation are favored by a low-voltage area located at well-identified epicardial bundles. Comprehensive entrainment pacing maneuvers are crucial to distinguish pseudo-focal ATs from true focal ATs. Blocking the anatomical isthmus is a better therapeutic option than ablating the breakthrough site.

Peer review status:ACCEPTED

04 Jun 2021Submitted to Journal of Cardiovascular Electrophysiology
14 Jun 2021Submission Checks Completed
14 Jun 2021Assigned to Editor
15 Jun 2021Reviewer(s) Assigned
22 Jun 2021Review(s) Completed, Editorial Evaluation Pending
28 Jun 2021Editorial Decision: Revise Minor
20 Jul 20211st Revision Received
20 Jul 2021Submission Checks Completed
20 Jul 2021Assigned to Editor
20 Jul 2021Reviewer(s) Assigned
20 Jul 2021Review(s) Completed, Editorial Evaluation Pending
21 Jul 2021Editorial Decision: Accept