• 52 year-old male• Paroxysmal AF and AFL for 10 years, almost persistent.• Symptomatic and refractory to propafenone and amiodarone.• History of type II diabetes and two times of stroke.• Coronary artery was normal, and no other structure heart disease.• Echocardiography: LAD=35 mm, preserved LV function, no intracardiac thrombus from TEE

History of Patient

Intracardiac Recordings

Rapid activities inside the LSPV

First Step: Pulmonary Vein Isolation

Slowing of LSPV activities AF procedural termination during LPV isolation

Inducible Clinically Documented AFL-I (CL=237 msec)

Positive concordance of F wave in the precordial leads:

Negative in aVL

Positive in inferior leads and V1

Flat in lead I

Questions-1

What is the organized tachycardia from polarities of surface ECG P waves?

(A) CW RA atrial flutter.

(B) CCW RA atrial flutter.

(C) Atypical RA atrial flutter.

(D) Atypical LA atrial flutter.

Negative in aVL

Almost flat in V2-V6

Positive in inferior leads and lead V1

Inducible Clinically Documented AFL-2 (CL=218 msec)

Negative in lead I

Questions-2

What is the organized tachycardia from polarities of surface ECG P waves?

(A) CW RA atrial flutter.

(B) CCW RA atrial flutter.

(C) Atypical RA atrial flutter.

(D) Atypical LA atrial flutter.

Summary of F wave Morphology after PV Isolation

Marchlinski group 2007, JCE

RPV AT LPV AT

Counter-C

Mitral Flutter

ClockwiseMitral Flutter

Clockwise RA AFL

Counter-C RA AFL

I + or +/- Flat or +/- Flat or - + +/- Flat or -

aVL + - - + + +/-II,III,aVF + + + - + -V1 + + + + - +V2-V6 + + + -/+ + -

Positive concordance in precordial leads or negative in aVL indicated LA tachycardias

Activation Map of the First AFLLPV Reentry

LSPV

LIPV

RSPV

RIPV

MV

Opposite activation of anterior wall and posterior wall of LA

Immediately after Roof Line ablation:Convert to 2nd AFL: Mitral AFL

LSPV

LIPV

LSPV

RSPV

RIPV

MV

Same direction of activation (low to high) in the anterior and posterior wall of LA

LSPV RSPV

MV

Posterior wall

Rapid activities in the RA

LSPV was silent

AFL Converted to AF and Terminatedduring Mitral Line Ablation

AF terminated

AFL AF

Question-3 What is the mechanism of conversion from atypical

atrial flutter to atrial fibrillation and termination ?

(A) Radiofrequency ablation of lateral mitral line.

(B) Rapid firing of PV or non-PV AF triggers.

(C) Breaks in functional block lines in the atrial substrate.

(D) Multiple mechanisms.

Positive in lead II and Biphasic in lead V1

Spontaneous Burst Triggers after AFL Termination

Reverse of atrial potential from RSPV recording

Intracardiac recordingsRA Catheter in the High RA

Intracardiac recording

RSPV

RA

Similar CS sequence of sinus beat and triggers

Fluoroscopy : RAO view

RA catheter

Question-4

Where are the AF initiators after 4PVI+lines? What is the next step?

(A) From the superior vena cava and isolate SVC.

(B) Immediate recurrence of right superior pulmonary vein and re-isolate the right superior PV.

(C) Far-field potentials from right inferior pulmonary vein and re-isolate the right inferior PV.

(D) Stop the procedure after 4 PVI and lines ! This may be not clinically relevant!

Advance the High RA Catheter into SVC

RSPV

SVC

High-to-low sequence during APCs

Intracardiac recordingFluoroscopy : RAO view

RA catheter

Right atrium

SVC

Question-5 Which item can differentiate the triggers from SVC or RSPV?

(A) P wave morphology of surface electrograms .

(B) Reverse of double potentials from RSPV recordings (as RSPV triggers).

(C) Simultaneous intracardiac recording (RSPV and RA catheter) to see the earliest activation site.

(D) High-to-low sequence in the SVC recording during ectopic beats

(E) All of above

- Configuration of surface ECG - Lead V1: Positive in all patients with RSPV-AF, only

47% in SVC-AF patients.- Lead avL: Biphasic in most SVC-AF patients.

- Intracardiac recordings: - High-to-low sequence of SVC recording.- Timing difference between HRA-His recording and CS

activation sequence.- Reverse of double potentials in thoracic vein

recordings (SVC and RSPV potentials).- During incessant AF: rapid activities near the SVC- ostium

or inside the SVC compared to LA recordings indicated

SVC in origin.

Tips of identification of SVC triggers

Tsai Circulation 2000; Kuo JCE 2003; Lin JACC 2006

Questions-6

Which procedure is necessary before SVC isolation?

(A) Reconfirm the origin of sinus node.

(B) Reconfirm the orifice by angiography or reconstructed CT scanning.

(C) High current stimulation along the anterior and lateral aspects of SVC-RA junction and observe the motion of diaphragm.

(D) All of above.

Isolation of Superior Vena Cava

Confirm the SAN origin first by RA activation mapping

RA free wall

LA

LSPV

RSPV

Confirm the orifice of SVC by angiography