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Prevention of Atrial Flutter With Cryoablation May Be Proarrhythmogenic Peter Lukac, MD, PhD, Vibeke E. Hjortdal, MD, PhD, Anders K. Pedersen, MD, DMSc, Peter T. Mortensen, MD, Henrik K. Jensen, MD, PhD, Peter S. Hansen, MD, PhD The Annals of Thoracic Surgery Volume 83, Issue 5, Pages 1717-1723 (May 2007) DOI: 10.1016/j.athoracsur.2007.01.022 Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Schematic of the cryolesion in the right atrium. (AFL = circuit of atrial flutter; CT = crista terminalis; IAT = circuit of the incisional atrial tachycardia; IVC = inferior vena cava; SVC = superior vena cava; TA = tricuspid annulus.) The Annals of Thoracic Surgery 2007 83, 1717-1723DOI: (10.1016/j.athoracsur.2007.01.022) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Measurement of conduction delay. The time from the pacing spike until the local unipolar electrogram on the contralateral side of the cryolesion was measured on a commercially available electrocardiograph. (A = local unipolar electrogram; QRS = far field QRS complex; S = pacing spike.) The Annals of Thoracic Surgery 2007 83, 1717-1723DOI: (10.1016/j.athoracsur.2007.01.022) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Conduction block in the cryolesion between the incision and TA in superior-inferior direction in patient 3 after radiofrequency ablation. Electroanatomic map of the right atrium is shown in the right anterior oblique (left panel) and left anterior oblique (right panel) projection. Activation sequence is coded in color from red through yellow, green, blue, to purple. Pacing site is located on the superior side of the cryolesion. Cryolesion is depicted by the blue dots representing double potentials, pacing site by the yellow dot, and ablation site by the red dot. The impulse must go the whole way around the scar (visible in the left panel) and TA (right panel), respectively, to reach the caudal aspect of the cryolesion, demonstrating complete block. (PS = pacing site; RF = radiofrequency ablation site; SCAR = scar at the site of the atriotomy; TA = tricuspid annulus.) The Annals of Thoracic Surgery 2007 83, 1717-1723DOI: (10.1016/j.athoracsur.2007.01.022) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Figure-of-eight intraatrial reentry tachycardia in patient 3, demonstrating conduction across the cryolesion between the incision and TA in the superior–inferior direction. Electroanatomic map of the right atrium is shown in the right lateral (left panel) and left lateral (right panel) projection. Activation sequence is coded in color as in Figure 3. One wavefront is coming clockwise around the incision (left panel) and the other counter clockwise around TA (right panel; we look through the TA at the scar at the lateral wall from the inside). Both merge to pass through the common channel between the atriotomy and TA. Cryolesion is depicted by the blue dots representing double potentials. (SCAR = scar at the site of the atriotomy; TA = tricuspid annulus.) The Annals of Thoracic Surgery 2007 83, 1717-1723DOI: (10.1016/j.athoracsur.2007.01.022) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Minimal temperature reached during cryolesion formation between the incision and the tricuspid annulus in patients with bidirectional conduction block and no bidirectional block. The Annals of Thoracic Surgery 2007 83, 1717-1723DOI: (10.1016/j.athoracsur.2007.01.022) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions