A Case with Macroreentrant Atrial Tachycardia around Sinus Venosa Region—Demonstration of Conduction across Crista Terminalis after Cavotricuspid Isthmus Block—

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A 66-year-old mas was referred to our hospital for frequent episodes of palpitation. 12-lead ECG showed typical atrial flutter (AFL) with 2:1 atrioventricular conduction, which spontaneously turned into atrial fibrillation (AF). Radiofrequency (RF) ablation was performed and circumferential pulmonary vein isolation was successfully achieved. Linear ablation of cavotricuspid isthmus (CTI) was also added for typical AFL and bidirectional conduction block at the isthmus was confirmed by widely splited double potentials recorded at CTI and significant prolongation of conduction time between coronary sinus ostium (CSos) and low lateral right atrium (LLRA). Subsequently, atrial tachycardia (AT) was induced by atrial burst pacing. During the AT, electroanatomical mapping showed macroreentry pattern around the sinus venosa region, where double potentials were recorded by a mapping catheter. Ablation was performed during AT to create block line between sinus venosa and inferior vena cava and AT terminated during RF application. After completion of the block line, conduction time between CSos and LLRA prolonged from 152 ms to 169 ms. This is the first case report that could demonstrate the conduction across crista terminalis in a case with typical AFL.