Association of Rate-Dependent Conduction Block between Eccentric Coronary Sinus to Left Atrial Connections with Inducible Atrial Fibrillation and Flutter

Dong Huang, Joseph Marine, Jing Bo Li, Tarek Zghaib, Esra Gucuk Ipek, Sunil Sinha, David D Spragg, Hiroshi Ashikaga, Ronald D Berger, Hugh Calkins, Saman Nazarian

Research output: Contribution to journalArticle

Abstract

Background - We sought to describe the prevalence and variability of coronary sinus (CS) and left atrial (LA) myocardium connections, their susceptibility to rate-dependent conduction block, and association with atrial fibrillation (AF) and flutter induction. Methods and Results - The study cohort included 30 consecutive AF patients (age 63.3±10.5 years, 63% male). Multipolar catheters were positioned in the CS, high right atrium (HRA), and LA parallel to and near the CS. Trains of 10 pacing stimuli were delivered during sinus rhythm from each of the following sites: CS proximal (CSp), CS distal (CSd), LA septum (LAs), lateral LA (LAl), and HRA, at the following cycle lengths: 1000, 500, 400, 300, and 250 ms, while recording from the other catheters. With the CS 9 to 10 bipole just inside the CS ostium, CS-LA connections were observed in 100% at CS 9 to 10, 30% at CS 7 to 8, 23% at CS 5 to 6, 23% at CS 3 to 4, and 97% at CS 1 to 2. Eighteen patients (60%) had AF/atrial flutter induced. Rate-dependent conduction block of a CS-LA connection at cycle length of ≥250 ms was present in 17 (94%) of those with versus none of those without AF/atrial flutter induction (P<0.001). Conclusions - Rate-dependent eccentric CS-LA conduction block is associated with AF/atrial flutter induction in patients with drug-refractory AF undergoing ablation. The presence of dual muscular CS-LA connections, coupled with unidirectional block in one limb, seems to serve as a substrate for single or multiple reentry beats, and arrhythmia induction.

Original languageEnglish (US)
Article numbere004637
JournalCirculation: Arrhythmia and Electrophysiology
Volume10
Issue number1
DOIs
StatePublished - Jan 1 2017

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Atrial Flutter
Coronary Sinus
Atrial Fibrillation
Heart Atria
Catheters
Atrial Septum

Keywords

  • Atrial fibrillation
  • Atrial flutter
  • Catheter ablation
  • Coronary sinus
  • Myocardium

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

@article{f58254e450ab47d09216090a0a188d3f,
title = "Association of Rate-Dependent Conduction Block between Eccentric Coronary Sinus to Left Atrial Connections with Inducible Atrial Fibrillation and Flutter",
abstract = "Background - We sought to describe the prevalence and variability of coronary sinus (CS) and left atrial (LA) myocardium connections, their susceptibility to rate-dependent conduction block, and association with atrial fibrillation (AF) and flutter induction. Methods and Results - The study cohort included 30 consecutive AF patients (age 63.3±10.5 years, 63{\%} male). Multipolar catheters were positioned in the CS, high right atrium (HRA), and LA parallel to and near the CS. Trains of 10 pacing stimuli were delivered during sinus rhythm from each of the following sites: CS proximal (CSp), CS distal (CSd), LA septum (LAs), lateral LA (LAl), and HRA, at the following cycle lengths: 1000, 500, 400, 300, and 250 ms, while recording from the other catheters. With the CS 9 to 10 bipole just inside the CS ostium, CS-LA connections were observed in 100{\%} at CS 9 to 10, 30{\%} at CS 7 to 8, 23{\%} at CS 5 to 6, 23{\%} at CS 3 to 4, and 97{\%} at CS 1 to 2. Eighteen patients (60{\%}) had AF/atrial flutter induced. Rate-dependent conduction block of a CS-LA connection at cycle length of ≥250 ms was present in 17 (94{\%}) of those with versus none of those without AF/atrial flutter induction (P<0.001). Conclusions - Rate-dependent eccentric CS-LA conduction block is associated with AF/atrial flutter induction in patients with drug-refractory AF undergoing ablation. The presence of dual muscular CS-LA connections, coupled with unidirectional block in one limb, seems to serve as a substrate for single or multiple reentry beats, and arrhythmia induction.",
keywords = "Atrial fibrillation, Atrial flutter, Catheter ablation, Coronary sinus, Myocardium",
author = "Dong Huang and Joseph Marine and Li, {Jing Bo} and Tarek Zghaib and Ipek, {Esra Gucuk} and Sunil Sinha and Spragg, {David D} and Hiroshi Ashikaga and Berger, {Ronald D} and Hugh Calkins and Saman Nazarian",
year = "2017",
month = "1",
day = "1",
doi = "10.1161/CIRCEP.116.004637",
language = "English (US)",
volume = "10",
journal = "Circulation: Arrhythmia and Electrophysiology",
issn = "1941-3149",
publisher = "Lippincott Williams and Wilkins",
number = "1",

}

TY - JOUR

T1 - Association of Rate-Dependent Conduction Block between Eccentric Coronary Sinus to Left Atrial Connections with Inducible Atrial Fibrillation and Flutter

AU - Huang, Dong

AU - Marine, Joseph

AU - Li, Jing Bo

AU - Zghaib, Tarek

AU - Ipek, Esra Gucuk

AU - Sinha, Sunil

AU - Spragg, David D

AU - Ashikaga, Hiroshi

AU - Berger, Ronald D

AU - Calkins, Hugh

AU - Nazarian, Saman

PY - 2017/1/1

Y1 - 2017/1/1

N2 - Background - We sought to describe the prevalence and variability of coronary sinus (CS) and left atrial (LA) myocardium connections, their susceptibility to rate-dependent conduction block, and association with atrial fibrillation (AF) and flutter induction. Methods and Results - The study cohort included 30 consecutive AF patients (age 63.3±10.5 years, 63% male). Multipolar catheters were positioned in the CS, high right atrium (HRA), and LA parallel to and near the CS. Trains of 10 pacing stimuli were delivered during sinus rhythm from each of the following sites: CS proximal (CSp), CS distal (CSd), LA septum (LAs), lateral LA (LAl), and HRA, at the following cycle lengths: 1000, 500, 400, 300, and 250 ms, while recording from the other catheters. With the CS 9 to 10 bipole just inside the CS ostium, CS-LA connections were observed in 100% at CS 9 to 10, 30% at CS 7 to 8, 23% at CS 5 to 6, 23% at CS 3 to 4, and 97% at CS 1 to 2. Eighteen patients (60%) had AF/atrial flutter induced. Rate-dependent conduction block of a CS-LA connection at cycle length of ≥250 ms was present in 17 (94%) of those with versus none of those without AF/atrial flutter induction (P<0.001). Conclusions - Rate-dependent eccentric CS-LA conduction block is associated with AF/atrial flutter induction in patients with drug-refractory AF undergoing ablation. The presence of dual muscular CS-LA connections, coupled with unidirectional block in one limb, seems to serve as a substrate for single or multiple reentry beats, and arrhythmia induction.

AB - Background - We sought to describe the prevalence and variability of coronary sinus (CS) and left atrial (LA) myocardium connections, their susceptibility to rate-dependent conduction block, and association with atrial fibrillation (AF) and flutter induction. Methods and Results - The study cohort included 30 consecutive AF patients (age 63.3±10.5 years, 63% male). Multipolar catheters were positioned in the CS, high right atrium (HRA), and LA parallel to and near the CS. Trains of 10 pacing stimuli were delivered during sinus rhythm from each of the following sites: CS proximal (CSp), CS distal (CSd), LA septum (LAs), lateral LA (LAl), and HRA, at the following cycle lengths: 1000, 500, 400, 300, and 250 ms, while recording from the other catheters. With the CS 9 to 10 bipole just inside the CS ostium, CS-LA connections were observed in 100% at CS 9 to 10, 30% at CS 7 to 8, 23% at CS 5 to 6, 23% at CS 3 to 4, and 97% at CS 1 to 2. Eighteen patients (60%) had AF/atrial flutter induced. Rate-dependent conduction block of a CS-LA connection at cycle length of ≥250 ms was present in 17 (94%) of those with versus none of those without AF/atrial flutter induction (P<0.001). Conclusions - Rate-dependent eccentric CS-LA conduction block is associated with AF/atrial flutter induction in patients with drug-refractory AF undergoing ablation. The presence of dual muscular CS-LA connections, coupled with unidirectional block in one limb, seems to serve as a substrate for single or multiple reentry beats, and arrhythmia induction.

KW - Atrial fibrillation

KW - Atrial flutter

KW - Catheter ablation

KW - Coronary sinus

KW - Myocardium

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U2 - 10.1161/CIRCEP.116.004637

DO - 10.1161/CIRCEP.116.004637

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