Biatrial flutter circuit involving an anomalous insertion of the Bachmann bundle into the superior vena cava Ely Gracia, MD, Roger Fan, MD, FHRS HeartRhythm.

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Biatrial flutter circuit involving an anomalous insertion of the Bachmann bundle into the superior vena cava Ely Gracia, MD, Roger Fan, MD, FHRS HeartRhythm Case Reports Volume 4, Issue 8, Pages 353-355 (August 2018) DOI: 10.1016/j.hrcr.2018.04.014 Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 1 Anomalous connection from the superior vena cava (SVC) to Bachmann bundle (BB) demonstrated by activation mapping of the right atrium (RA) and SVC while pacing the left atrial appendage. The asterisk denotes insertion of BB into the SVC. CS = coronary sinus. HeartRhythm Case Reports 2018 4, 353-355DOI: (10.1016/j.hrcr.2018.04.014) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 2 A: Entrainment from the distal coronary sinus (CSd) with concealed fusion and postpacing interval-tachycardia cycle length (PPI-TCL) = 0 ms. B: Entrainment from the superior vena cava with concealed fusion and PPI-TCL = 9 ms. Despite the close proximity of the proximal HALO catheter (HALOp; Boston Scientific, Marlborough, MA) pole to the superior vena cava pacing site (distal ablation catheter [ABLd]), late activation is seen, noted by the advancement of the HALOp electrogram to the pacing cycle length of 280 ms. This indicates late downstream activation of the HALOp site in the reentrant atrial flutter circuit. Red asterisks denote pacing sites. Positioning of the HALO catheter in the right atrium and coronary sinus catheter is illustrated in Figure 3A. ABLp = proximal ablation catheter; CSp = proximal coronary sinus; HALOd = distal HALO catheter. HeartRhythm Case Reports 2018 4, 353-355DOI: (10.1016/j.hrcr.2018.04.014) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 3 A: Activation map of the biatrial flutter circuit. The asterisk denotes anomalous connection between the superior vena cava (SVC) and Bachmann bundle (BB). By isolating the SVC, biatrial flutter was successfully treated. B: After anterior mitral ablation (red bar), the substrate for biatrial flutter is established because of conduction block on the left atrium (LA) septum, allowing reentry involving BB and the interatrial septum. CS = coronary sinus; RA = right atrium. HeartRhythm Case Reports 2018 4, 353-355DOI: (10.1016/j.hrcr.2018.04.014) Copyright © 2018 Heart Rhythm Society Terms and Conditions