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Incremental His-to-coronary sinus maneuver: a nonlocal electrogram-based technique to assess complete cavotricuspid
Ermengol Vallès1, Victor Bazán, Begoña Benito
1Electrophysiology Unit, Cardiovascular Division, Department of Medicine, Hospital del Mar Universitat Autònoma de Barcelona, Barcelona, Spain.
Insights
Confirming complete cavotricuspid isthmus (CTI) block after ablation is crucial for preventing atrial flutter. A new incremental pacing maneuver effectively distinguishes complete CTI block from slow conduction, improving ablation success rates.
Area of Science:
- Electrophysiology
- Cardiac Ablation
- Arrhythmia Management
Background:
- Complete cavotricuspid isthmus (CTI) conduction block is essential for reducing typical atrial flutter recurrence post-ablation.
- Assessing CTI block can be challenging due to slow conduction or inconclusive electrograms.
Purpose of the Study:
- To evaluate a novel incremental His-to-coronary sinus ostium (H-CoS) maneuver for confirming complete CTI block.
- To compare the efficacy of the H-CoS maneuver with the established incremental pacing (IP) maneuver.
Main Methods:
- Sixty-six patients undergoing CTI ablation were prospectively studied.
- The H-CoS maneuver involved incremental pacing from the low lateral right atrium, measuring the H-CoS interval.
- Results were compared to the standard IP maneuver for CTI block confirmation.
Main Results:
- The H-CoS maneuver accurately identified functional CTI block (phase 1) in all cases.
- It conclusively confirmed complete CTI block (phase 2) in 98% of patients, comparable to the IP maneuver.
- The H-CoS maneuver proved effective even when local electrograms were inconclusive.
Conclusions:
- The incremental H-CoS maneuver is a reliable alternative to the IP maneuver for assessing CTI block.
- This method enhances the ability to confirm CTI block, especially in challenging cases with unclear electrograms.
Background:
Achievement of complete cavotricuspid isthmus (CTI) conduction block reduces typical atrial flutter recurrences after ablation. The lack of increase in the His-to-coronary sinus ostium atrial interval during incremental pacing (IP) from the low lateral right atrium may distinguish slow conduction from complete CTI conduction block.
Methods And Results:
Sixty-six consecutive patients (age, 65±13 years; 18% female) were prospectively included. A <10 ms increase in the His-to-coronary sinus ostium atrial timing during low lateral right atrium IP at cycle length of 600 ms through 300 ms was compared with the previously reported IP maneuver for the confirmation of complete CTI block. On the basis of the IP maneuver, complete CTI block (phase 2) was achieved in 59 patients, in 13 of whom an intermediate phase of functional CTI block (phase 1) was observed. In the remaining 7 patients, the IP maneuver did not allow for assessment of complete CTI block because of the presence of inconclusive potentials in the CTI ablation line. As compared with the IP maneuver, the incremental His-to-coronary sinus ostium maneuver was consistent with functional CTI block during phase 1 in all cases and conclusive of complete CTI block in 98% of cases during phase 2.
Conclusions:
The incremental His-to-coronary sinus ostium maneuver is analogous to the IP maneuver in distinguishing complete CTI block from persistent CTI conduction. This maneuver may provide confirmation of CTI block in those patients in whom assessment of local electrogram-based criteria is not feasible because of inconclusive potentials in the CTI ablation line.
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