Tina Baykaner, MD, MPH, Joshua M. Cooper, MD, FHRS

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Date of download: 7/2/2016 Copyright © The American College of Cardiology. All rights reserved. From: Recognition of far-field electrograms during entrainment.

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Atypical flutter following lung transplantation involving recipient-to-donor tissue connections Tina Baykaner, MD, MPH, Joshua M. Cooper, MD, FHRS HeartRhythm Case Reports Volume 4, Issue 11, Pages 548-552 (November 2018) DOI: 10.1016/j.hrcr.2018.08.008 Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 1 A: Imported 3-dimensional computed tomography scan reconstruction of the recipient left atrium and donor pulmonary veins with attached antral cuff; a clipping plane is used to show an internal view of the left atrial anastomosis site for the transplanted left lung. B: Fluoroscopy view (right anterior oblique projection) of the decapolar circular catheter in position just inside the left pulmonary vein (PV) donor cuff. The 10 poles of the Lasso are labeled as per standard catheter nomenclature. C: The figure-of-8 flutter circuit is demonstrated. The red arrows show wavefront propagation in a posterior-to-anterior direction within the PV donor cuff (near-field signals), with simultaneous superior and inferior routes being taken after wavefront entry to the cuff via a recipient-to-donor connection near Lasso pole number 6. The green arrows show wavefront propagation in an anterior-to-posterior direction, simultaneously traveling via superior and inferior routes around the outside of the anastomosis in recipient left atrial tissue, having exited the cuff via a second donor-to-recipient connection near Lasso pole number 2 (far-field signals). D: Surface electrocardiogram and intracardiac electrograms as recorded during the atrial flutter, with a sweep speed of 100 mm/second. The circular mapping catheter (Lasso 1 – Lasso 10) is positioned as shown in panel B. Far-field electrograms demonstrate the portions of the figure-of-8 circuit that involve native recipient left atrial tissue (green arrows, which correspond to the green arrows in panel C). Near-field fractionated electrograms demonstrate the portions of the figure-of-8 circuit that involve donor antral cuff tissue (red arrows, which correspond to the red arrows in panel C). Note the continuous fractionated electrogram in Lasso 6 where the green arrows converge and the red arrows diverge, representing the posterior electrical connection from recipient to donor tissue. The coronary sinus catheter is activated in an eccentric fashion, and the crista terminalis catheter is activated late, consistent with the atrial propagation wavefront originating from the left pulmonary veins. Crista = crista terminalis; CS = coronary sinus. HeartRhythm Case Reports 2018 4, 548-552DOI: (10.1016/j.hrcr.2018.08.008) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 2 A: Imported and merged 3-dimensional computed tomography scan reconstruction of the left atrium, with a clipping plane revealing an internal view of the left atrial anastomosis for the left lung graft. The yellow asterisk marks the site where entrainment pacing from the ablation catheter was performed during the maneuver shown in panel C. Aqua markers denote some of the sites where entrainment pacing was performed. Red and pink markers denote ablation sites, as further described in the text and in Figure 3 (of note, ablation had not yet been performed at the time of the entrainment maneuver demonstrated in this figure). B: Fluoroscopy view (right anterior oblique projection) of the decapolar circular catheter in position just inside the left pulmonary vein donor cuff. The 10 poles of the Lasso are labeled as per standard catheter nomenclature. The yellow asterisk marks the site where entrainment pacing from the ablation catheter was performed during the maneuver shown in panel C. C: During the clinical atypical atrial flutter, an entrainment maneuver is performed from the ablation catheter, which was positioned just outside the posterior recipient-to-donor electrical connection (yellow asterisk in panels A and B). There is acceleration of the tachycardia to the 200 ms pacing cycle length, and slight manifest fusion as noted on all surface electrocardiography leads and in all intracardiac electrograms with very minimal changes in morphology, and the postpacing interval was 220 ms, the same as the tachycardia cycle length, demonstrating that this site was in the tachycardia circuit. Delayed activation in the coronary sinus and right atrial sites suggest significant intra-atrial conduction delay during tachycardia. Of note, the postpacing interval was equal to the tachycardia cycle length at all aqua-marked entrainment sites in panel A. The sweep speed in this figure is 100 mm/second. Abl-D = ablation catheter distal electrode pair; Abl-P = ablation catheter proximal electrode pair; Crista = crista terminalis; CS = coronary sinus. HeartRhythm Case Reports 2018 4, 548-552DOI: (10.1016/j.hrcr.2018.08.008) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 3 A: Surface electrocardiogram and intracardiac electrograms, recorded at a sweep speed of 50 mm/second, during radiofrequency ablation at the site marked in panel B. When radiofrequency energy is applied near Lasso 6, representing the electrical entry site where the flutter circuit traversed from recipient left atrium into donor pulmonary vein (PV) antral cuff, the tachycardia terminated (red asterisk). Note that the far-field electrograms from the native left atrial portion of the figure-of-8 circuit were inscribed (green arrows in Figure 1), but the tachycardia terminates before the near-field electrograms inside the donor cuff were inscribed (red arrows in Figure 1), consistent with termination at the posterior entry site electrical connection. With return of the first sinus beat after tachycardia termination, there is reversal of activation inside the PV cuff (red arrows), now with earliest cuff activation near Lasso electrodes 1 and 2, which previously served as the exit site during tachycardia. B: Imported and merged 3-dimensional computed tomography scan reconstruction of the left atrium, with a clipping plane revealing an internal view of the left atrial anastomosis for the left lung graft. The red asterisk marks the ablation site as shown in panel A, where the tachycardia terminated (also marked by the nearby red markers on the map). The anterior red and pink markers denote ablation sites subsequently performed at the second donor-to-native reconnection, which isolated the donor PV cuff and resulted in isolated, dissociated electrical firing within the cuff of donor tissue. C: Fluoroscopy view (right anterior oblique projection) of the decapolar circular catheter in position just inside the left PV donor cuff. The 10 poles of the Lasso are labeled as per standard catheter nomenclature. Red arrows correlate with the red arrows in panel A and demonstrate the route of anterior electrical wavefront entry from recipient left atrial tissue into the donor PV cuff during sinus rhythm after initial radiofrequency ablation was performed, which had terminated the tachycardia and eliminated the posterior recipient-to-donor connection (red asterisk). Further ablation was subsequently performed at the anterior connection, thereby achieving complete electrical isolation of the donor PV cuff. Abl-D = ablation catheter distal electrode pair; Crista = crista terminalis; CS = coronary sinus. HeartRhythm Case Reports 2018 4, 548-552DOI: (10.1016/j.hrcr.2018.08.008) Copyright © 2018 Heart Rhythm Society Terms and Conditions