Author + information
- Received November 29, 2018
- Revision received December 18, 2018
- Accepted December 20, 2018
- Published online April 15, 2019.
- Hideki Koike, MD, PhDa,b,∗ (, )
- Kazuyuki Yahagi, MDa,
- Hitomi Yuzawa, MDb,
- Kei Sato, MDa,
- Masahiko Asami, MDa,
- Kota Komiyama, MDa,
- Jun Tanaka, MDa,
- Jiro Aoki, MDa,
- Kengo Tanabea and
- Takanori Ikeda, MD, PhDb
- aDivision of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
- bDepartment of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
- ↵∗Address for correspondence:
Dr. Hideki Koike, Mitsui Memorial Hospital, Division of Cardiology, Kanda-Izumi-cho 1, Chiyoda-ku, Tokyo 101-8643, Japan.
A 51-year-old woman with cardiac sarcoidosis presented with 2:1 atrial flutter (AFL) (Figure 1Ai) and was referred for catheter ablation. During sinus rhythm, a 12-lead electrocardiogram revealed trifascicular block (Figure 1Aii). Echocardiography revealed basal thinning of the interventricular and atrial septum, which was also enhanced in cardiac magnetic resonance imaging and positron emission tomography–computed tomography (Figures 1B to 1D). In the intracardiogram, the coronary sinus sequence suggested left atrial AFL. Additionally, the right atrial activation time did not cover the full cycle length. However, 3-dimensional -sparkle mapping revealed that the AFL rotated up the lateral right atrial wall and through the Bachmann bundle, and further, from the distal to proximal coronary sinus and cavo-tricuspid isthmus (CTI) (Figure 2, Online Video 1). Entrainment and 3-dimensional mapping suggested CTI dependence and the AFL could be terminated by a CTI ablation. There were fragmental potentials around the septal wall, which was enhanced in cardiac magnetic resonance imaging, suggesting a septal conduction disturbance causing unidirectional block in the coronary sinus ostium. Conduction disturbances are generally observed in cardiac sarcoidosis (1); however, the present case is rare, demonstrating a CTI-dependent AFL rotating around both atria due to an atrial-septal conduction disturbance.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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- Received November 29, 2018.
- Revision received December 18, 2018.
- Accepted December 20, 2018.
- 2019 American College of Cardiology Foundation