Intra-atrial Reentrant Tachycardia After Palliation of Congenital Heart Disease: Characterization of Multiple Macroreentrant Circuits Using Fluoroscopically Based Three-dimensional Endocardial Mapping

Introduction: The anatomic substrate of intra-atrial reentrant tachycardia (IART) following congenital heart surgery is poorly understood, but is presumed to be different than common atrial flutter.

Methods And Results: To study the mechanisms of IART, we used a new technique for high-density endocardial mapping using recordings from a multipolar basket recording catheter (25 bipolar pairs). For each recording, biplane fluorographic reference points were digitized to obtain the spatial locations of electrode pairs, and activation times were calculated using temporal reference points from the surface ECG. Using custom software, data were combined to create three-dimensional atrial activation sequence maps, which were displayed as animated sequences. Using this technique, recordings were made in induced and/or spontaneous IART in 8 patients following congenital heart surgery (5 Fontan, 2 tetralogy of Fallot repair, 1 ventricular septal defect repair), and in 3 patients with normal intracardiac anatomy (1 with type I atrial flutter). Ten discrete IART activation sequences were recorded; 2 patients had 2 sequences each. IART maps were constructed using a median of 108 electrode positions (range 27 to 197) from a median of 6 recordings/sequence (range 3 to 11). Sinus or paced atrial rhythms were also recorded, and maps were created in a similar fashion. Visual analysis of activation sequences of sinus and paced rhythm were anatomically concordant with known mechanisms of atrial activation. IART sequences revealed diverse mechanisms; only 1 IART circuit was similar to that associated with common atrial flutter. Activation wavefront emergence from presumed zones of slow conduction, lines of conduction block, and apparent bystander activation were observed.

Conclusions: High-density atrial activation sequence maps demonstrate that IART following congenital heart surgery utilizes diverse circuits and is distinct from common atrial flutter. The technique used to create these three-dimensional activation sequences may improve understanding of these complex atrial arrhythmias and assist in the development of ablative therapies.