Participation of epicardial connection in transverse conduction across the crista terminalis in patients with upper and lower loop reentry atrial tachycardias

Abstract Background The crista terminalis (CT) sometimes serves as a partial or complete conduction barrier, which is rate- and site-dependent. The basis, location and extent of the transverse conduction across the CT have been controversial. The pseudo-focal activation pattern indicates passive activation from the anatomically opposite chamber or structure. We previously reported cases of transverse CT conduction exhibiting a pseudo-focal activation pattern, indicating the CT conduction utilizing an epicardial connection (EC) in patients with upper loop reentry (ULR) atrial tachycardia (AT). Purpose This study aimed to investigate the prevalence and characteristics of transverse CT conduction using a high-resolution electroanatomical mapping system during CT-dependent AT and to compare between the ULR and lower loop reentry (LLR) ATs. Methods A total of 119 consecutive patients with macroreentrant AT were studied. The diagnosis of ULR/LLR AT was made based on endocardial activation mapping and entrainment pacing obtained from various sites around the superior/inferior vena cava. Transverse CT conduction utilizing an EC was defined as follows; (1) a centrifugal activation pattern with the earliest activation (EA) site >5 mm away from the CT, (2) later activation observed between the EA and the CT, and (3) the EA site exhibiting a pseudo-focal activation pattern (multiple breakthroughs or a small r wave on unipolar electrogram). Results Eighteen (15.1%) of the 119 patients were diagnosed with CT-dependent AT (15 men; median age, 71.5 years; AT cycle length, 265 ms; left atrial diameter, 42.5 mm; left ventricular ejection fraction, 49%). The 18 patients were divided into 2 groups: 9 patients with ULR and 9 with LLR AT. There were no significant differences in clinical characteristics (sex, history of cardiac surgery and organic heat disease) between ULR and LLR groups. Transverse CT conduction utilizing EC was more frequently observed in the ULR group than in the LLR group [77.8% (7/9) vs 22.2% (2/9), P=0.05]. In all patients with transverse CT conduction utilizing EC, scars extended along the CT. AT cycle length was significantly longer in the ULR group than in the LLR group (295 vs 235 ms, p=0.001). All ATs were successfully eliminated by radiofrequency ablation at the breakthrough sites and/or along the CT in ULR patients or by cavotricuspid isthmus ablation in LLR patients. Conclusions Half (9/18) of the patients with CT-dependent AT exhibited transverse CT conduction with a pseudo-focal activation pattern, suggesting the existence of an EC between the sinus venosus and the right auricle. The high prevalence of the pseudo-focal pattern in patients with the ULR compared to those with the LLR may provide insights into mechanisms.Figure1Figure2