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Conduction delay across the cavotricuspid isthmus block line caused by the gap near the inferior vena cava: the role of conduction block in the lower lateral right atrium

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Abstract

The electrophysiological properties of the gap associated with the cavotricuspid isthmus (CTI) block line near the inferior vena cava (IVC) are not fully elucidated. Of 143 patients who underwent CTI block line ablation between September 2020 and April 2021, high-resolution CTI gap mapping was performed for 15 patients. Four patients were identified as having a gap near the IVC (IVC-side gap) despite wide double potentials (DPs) with > 90 ms intervals at the block line. Detailed gap mapping during coronary sinus ostial pacing was performed before and after touch-up ablation. CTI conduction delays caused by an IVC-side gap were classified into 3 patterns: (1) conduction delay at the IVC-side gap without detouring gap conduction, (2) detouring gap conduction due to intrinsic lower lateral right atrium (LLRA)-IVC functional block, and (3) detouring gap conduction due to LLRA-IVC conduction block created by lateral deviation of the CTI ablation line. In Pattern 2, IVC-side gap conduction traveled backward toward the crista terminalis below the LLRA-IVC junction and came back forward again above the border. One patient presented with a head-to-bottom activation pattern of the lateral right atrium (pseudo-CTI block). Pattern 3 was caused by lateral deviation of initial RF deliveries and presented with the same course as intrinsic LLRA-IVC functional block. All patients had wide DP intervals near the tricuspid annulus (mean, 112 ms) and just above the gap site (mean, 109 ms). An IVC-side gap associated with the CTI block line can present with various conduction delay patterns.

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Acknowledgements

We greatly appreciate the support provided by clinical engineers at our hospital.

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Authors and Affiliations

  1. Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan

    Takayuki Sekihara, Shinsuke Miyazaki, Kanae Hasegawa, Daisetsu Aoyama, Minoru Nodera, Tomoya Eguchi, Moeko Nagao, Shota Kakehashi, Moe Mukai, Hiroyasu Uzui & Hiroshi Tada

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  1. Takayuki Sekihara
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  2. Shinsuke Miyazaki
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  3. Kanae Hasegawa
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  5. Minoru Nodera
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  6. Tomoya Eguchi
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  8. Shota Kakehashi
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  10. Hiroyasu Uzui
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Corresponding author

Correspondence to Takayuki Sekihara.

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Conflict of interest

Dr. Miyazaki belonged to the endowed departments of Medtronic, Boston, Abbott, and Japan Lifeline.

Ethics approval

The study protocol was approved by the hospital’s institutional review board. The study complied with the Declaration of Helsinki.

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All patients gave their written informed consent.

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Online resource 1. Propagation map during coronary sinus ostial pacing before touch-up ablation in Patient 2 (MP4 5668 KB)

Online resource 2. Propagation map during coronary sinus ostial pacing before touch-up ablation in Patient 3 (MP4 8880 KB)

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Sekihara, T., Miyazaki, S., Hasegawa, K. et al. Conduction delay across the cavotricuspid isthmus block line caused by the gap near the inferior vena cava: the role of conduction block in the lower lateral right atrium. Heart Vessels 37, 1203–1212 (2022). https://doi.org/10.1007/s00380-021-02012-9

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  • DOI: https://doi.org/10.1007/s00380-021-02012-9

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