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CASE REPORT article

Front. Cardiovasc. Med.
Sec. Cardiac Rhythmology
Volume 11 - 2024 | doi: 10.3389/fcvm.2024.1420916

Epi-Endocardial Bridges in Refractory Cavotricuspid Isthmus-Dependent Atrial Flutter: Technical Analysis of Epi-Endocardial Breakthrough

Provisionally accepted
Andrea Matteucci Andrea Matteucci 1,2*Claudio Pandozi Claudio Pandozi 1Maurizio Russo Maurizio Russo 1Marco Galeazzi Marco Galeazzi 1Enrico Lombardi Enrico Lombardi 3Marco Valerio Mariani Marco Valerio Mariani 4Carlo Lavalle Carlo Lavalle 4Furio Colivicchi Furio Colivicchi 1
  • 1 Ospedale San Filippo Neri, Rome, Lazio, Italy
  • 2 Policlinico Tor Vergata, Rome, Italy
  • 3 Biosense Webster, Shfayim, Israel
  • 4 Sapienza University of Rome, Rome, Lazio, Italy

The final, formatted version of the article will be published soon.

    Background: Typical isthmus-dependent atrial flutter (AFL) is traditionally treated through radiofrequency (RF) ablation to create a bidirectional conduction block across the cavo-tricuspid isthmus (CTI) in the right atrium. While this approach is successful in many cases, certain anatomical variations can present challenges, making CTI ablation difficult.Methods: We enrolled four patients with typical counter-clockwise AFL who displayed an epicardial bridge at the CTI. Patients underwent high-resolution mapping of the right atrium and CTI ablation.Results: Post-mapping identified areas of early focal activation outside the lesion line which suggested the presence of an epi-endocardial bridge with an endocardial breakthrough, confirmed by recording a unipolar rS pattern on electrograms at that site. A stable CTI block was achieved in all patients only after ablation at the site of the epi-endocardial breakthrough.Conclusions: The presence of an epicardial bridge at the CTI, allowing conduction to persist despite endocardial ablation, should be considered in challenging cases of CTI-dependent AFL. Understanding this phenomenon and utilizing appropriate mapping and ablation techniques are essential for achieving successful and lasting CTI block.

    Keywords: cavo-tricuspid isthmus ablation, typical counter-clockwise atrial flutter, Epicardial bridge, epiendocardial breakthrough, High density mapping

    Received: 22 Apr 2024; Accepted: 24 Jul 2024.

    Copyright: © 2024 Matteucci, Pandozi, Russo, Galeazzi, Lombardi, Mariani, Lavalle and Colivicchi. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

    * Correspondence: Andrea Matteucci, Ospedale San Filippo Neri, Rome, 00135, Lazio, Italy

    Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.