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

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

doi:10.1161/CIRCEP.116.004637

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

Circ Arrhythm Electrophysiol. 2017 Jan;10(1):e004637. doi: 10.1161/CIRCEP.116.004637.

Authors

Affiliations

¹ From the Department of Cardiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiaotong University, China (D.H., J.-b.L.); Section for Cardiac Electrophysiology, Department of Medicine/Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (D.H., J.E.M., T.Z., E.G.I., S.S., D.D.S., H.A., R.D.B., H.C., S.N.); Section for Cardiac Electrophysiology, Department of Medicine/Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.).
² From the Department of Cardiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiaotong University, China (D.H., J.-b.L.); Section for Cardiac Electrophysiology, Department of Medicine/Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (D.H., J.E.M., T.Z., E.G.I., S.S., D.D.S., H.A., R.D.B., H.C., S.N.); Section for Cardiac Electrophysiology, Department of Medicine/Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). saman.nazarian@uphs.upenn.edu.

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 (CS_p), CS distal (CS_d), LA septum (LA_s), lateral LA (LA_l), 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.

Publication types

Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Atrial Fibrillation / physiopathology*
Atrial Fibrillation / surgery
Atrial Flutter / physiopathology*
Atrial Flutter / surgery
Cardiac Catheterization / methods
Cardiac Pacing, Artificial / methods
Catheter Ablation
Coronary Sinus / physiopathology
Female
Heart Atria / physiopathology
Heart Block / physiopathology*
Heart Conduction System / physiopathology
Heart Rate / physiology
Humans
Male
Middle Aged

Abstract

Publication types

MeSH terms

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