Ablation of Right-Sided Accessory Pathway with Atrial Insertion Site Located at Right Atrial Appendage Using Noncontact Mapping System

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A 16-year-old male with type B WPW syndrome was referred to our institute for ablative therapy. He experienced recurrent episodes of syncope following an attack of palpitation. The 12-lead electrocardiogram suggested a right anterior or anterolateral accessory atrioventricular connection. Electrophysiological study was performed using non-contact mapping system (NCM). Programmed electrical stimulation from the right atrium induced the orthodromic atrioventricular reciprocating tachycardia with a heart rate of 220 beats per minute and the blood pressure fell down to 65/30 mmHg. NCM showed the antegrade accessory pathway excitation travelling from the base of the right atrial appendage to anterolateral portion of the tricuspid annulus. Because several ablation attempts at the tricuspid annulus were not successful, activation mapping was performed during right ventricular pacing, which confirm the atrial insertion site was located at the basis of the right atrial appendage, as NCM revealed. Application of radiofrequency energy at this site eliminated the accessory pathway conduction. After 3-month follow-up, the patient had neither a recurrence of the preexcitation nor any episodes of syncope and palpitation. NCM could identify this unusual atrial insertion of the right-sided accessory pathway just observing the atrial excitation during sinus rhythm.
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