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Over the last decade there have been significant changes in the treatment of focal atrial tachycardia (AT).
This review concentrates on the different approaches to the treatment of focal AT. Initial therapies included
antiarrhythmic medications and surgery. However, with the advent of radiofrequency ablation, and the
poor efficacy of pharmacological therapy, there has been a shift toward a primary ablative approach.
Several different mapping techniques have been proposed. The different techniques, including P-wave
morphology and advanced three-dimensional mapping, are discussed in this review. (PACE 2006; 29:
769–778)
focal atrial, tachycardia, radio frequency ablation, therapy
C 2006, The Authors. Journal compilation
C 2006, Blackwell Publishing, Inc.
Figure 2. P-waves from atrial tachycardia from the low Figure 3. P-waves from the CS ostium and the supe-
and high CT. Note the positive-negative morphology in rior mitral annulus at the aortic-mitral continuity. Note
lead V 1 . These sites may be differentiated by the P-wave the similar P-wave morphologies in the precordial leads.
morphology in the inferior leads. The P-wave from infe- Atrial tachycardia arising from the CS ostium has neg-
rior sites is negative in the inferior leads and the superior ative P-waves in the inferior leads and positive P-waves
sites are positive. in lead aVL. The P-wave is negative in lead aVL in atrial
tachycardia from the superior mitral annulus and the in-
ferior leads are positive. The P-waves in the limb leads
are of low amplitude.
simply described as upright, this will lead to in-
correct localization to the left atrium. A positive
or biphasic P-wave in lead aVL indicates a right rior CT have positive P-waves in the inferior leads,
atrial focus with a sensitivity of 88%, specificity whereas the P-waves are isoelectric or biphasic in
of 79%, positive predictive accuracy of 83%, and these leads for mid cristal locations and negative
a negative predictive accuracy of 85%.19 for inferior foci.
While these criteria are useful to predict the
atrium of origin of AT foci, certain anatomic loca- CS Ostium
tions tend to be associated with specific P-wave The precordial leads display characteristic P-
morphologies. wave morphology in AT arising from the CS ostium
(Fig. 3). Lead V 1 has an initial component that is
Crista Terminalis either isoelectric or mildly inverted followed by an
The crista terminalis (CT) extends the length upright component.23 Across the precordial leads
of the RA and so there are a variety of P-wave mor- the initial component becomes more negative and
phologies from AT foci located on this structure the second component becomes isoelectric. Lead
(Fig. 2). The majority of AT from the mid and su- aVL is positive and the P-waves are deeply nega-
perior CT has biphasic P-waves in lead V 1 , sim- tive in the inferior leads. The P-wave morphology
ilar to the sinus P-wave, with an initial positive is similar to that of typical atrial flutter that has an
component followed by a negative component.21 exit zone at the CS ostium.24 Foci located within
AT from the low CT often have negative P-wave in the body of the CS will have a P-wave in V 1 , which
V 1 .21 The P-wave in lead I is positive from most CT is upright from the onset without an isoelectric seg-
sites. Lead aVR is negative.22 Tada et al.22 used this ment and P-waves are frequently upright across the
to differentiate posteriorly located crista sites from precordial leads.
more anteriorly located sites in the RA, which had
upright P-waves in aVR. The P-wave vector in the Atrial Septum
inferior leads is useful to determine where on the P-waves originating from an AT focus on
CT the AT focus arises.21 Foci located in the supe- the anterior and midseptum are narrower than
Figure 4. P-waves from the right perinodal region and Figure 5. P-waves from atrial tachycardia located on
the left side of the septum. P-wave morphology from both the inferior and superior TA. Note the negative P-waves
these regions may be variable. Note, in this case, the P- in the precordial leads, which are commonly notched.
wave from the right perinodal region is isoelectric in V 1 . Inferior locations have negative P-waves in the inferior
The P-wave from the left septum is negative-positive in leads. Superior locations have low amplitude P-waves
V 1 , similar to P-waves from the superior mitral annulus in the inferior leads. The P-wave morphology of atrial
and CS ostium. P-waves arising from the septum tend to tachycardia from the right atrial appendage is similar
be narrower than the sinus P-wave. to the superior TA.
Radiofrequency Ablation
Direct current shocks were the first form of Conclusion
catheter ablation therapy for the elimination of Assessment of the efficacy of antiarrhythmic
atrial foci.55 With the advent of radiofrequency therapy for focal AT is difficult due to the paucity
ablation this has become the treatment of choice of randomized controlled trials. However, there is
in patients with significant symptoms. AT abla- widespread agreement that antiarrhythmics have
tion series have reported success rates between low efficacy in the treatment of focal AT. With the
69% and 100%,3,21,35,37–39,41,44,46,48,50–53,56–59 with advent of radiofrequency ablation, there has been
a low incidence of complications. Reported com- a shift away from pharmacological therapy as long-
plications include pericardial effusion and tam- term cure may be achieved in a high proportion of
ponade,56 phrenic nerve paralysis,57 AV block,53,57 patients.
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