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\begin{document}

\title{Successful tricuspid annulus ablation for adenosine sensitive atrial
tachycardia originating from the mitral annulus.}



\author[1]{Ryosuke Takeuchi}%
\author[2]{natsuko hosoya}%
\author[3]{Yosuke Mizuno}%
\author[1]{Gaku Matsukura}%
\author[1]{Masayoshi Matsunari}%
\author[1]{Rumi Takabayashi}%
\author[1]{Mariko Ozeki}%
\author[1]{Takahiro Kanda}%
\author[1]{Kei Tawarahara}%
\author[4]{Akira Fujiki}%
\affil[1]{Hamamatsu Red Cross Hospital}%
\affil[2]{Hamamatsu Medical Center}%
\affil[3]{Shizuoka City Shizuoka Hospital}%
\affil[4]{Shizuoka Heart Rhythm Clinic}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
A 57-year-old man with repetitive long R--P supraventricular tachycardia
(SVT) was referred for radiofrequency catheter ablation. SVT was
sensitive to adenosine triphosphate, was not linked between atrial and
ventricular activation, and did not terminate with the ventricular
response; thus, we speculated reentrant atrial tachycardia (AT).
Although the mitral annulus (MA) was the earliest atrial activation site
(EAAS; 5 o'clock), AT was ablated not at the EAAS, but at the tricuspid
annulus (TA; 4 o'clock), 24 ms later than the EAAS. We suggest that
preferential conduction from the TA to the EAAS of the MA may be
involved in AT.%
\end{abstract}%



\sloppy


\textbf{Title} : Successful tricuspid annulus ablation for adenosine
sensitive atrial tachycardia originating from the mitral annulus.

\textbf{Authors} : Ryosuke Takeuchi MD,\textsuperscript{1,2} Natsuko
Hosoya MD,\textsuperscript{2,3} Yosuke Mizuno MD,\textsuperscript{2}Gaku
Matsukura MD,\textsuperscript{1} Masayoshi Matsunari
MD,\textsuperscript{1} Rumi Takabayashi MD,\textsuperscript{1} Mariko
Ozeki MD,\textsuperscript{1} Takahiro Kanda MD,\textsuperscript{1} Kei
Tawarahara MD,\textsuperscript{1} Akira Fujiki MD\textsuperscript{4}

\textbf{Affiliations} : \textsuperscript{1}Hamamatsu Red Cross
Hospital;\textsuperscript{2}Shizuoka City Shizuoka
Hospital;\textsuperscript{3}Hamamatsu Medical Center;
\textsuperscript{4}Shizuoka Heart Rhythm Clinic

\textbf{Corresponding author} : Ryosuke Takeuchi, Hamamatsu Red Cross
Hospital, 1088-1 Kobayashi, Hamakita-ku, Hamamatsu, 434-8533 Japan.
E-mail:\emph{oursbrun.ryo@gmail.com}.

\textbf{Disclosures} : The authors did not receive any financial support
and have no conflicts of interest to declare.

\textbf{Abstract} : A 57-year-old man with repetitive long R--P
supraventricular tachycardia (SVT) was referred for radiofrequency
catheter ablation. SVT was sensitive to adenosine triphosphate, was not
linked between atrial and ventricular activation, and did not terminate
with the ventricular response; thus, we speculated reentrant atrial
tachycardia (AT). Although the mitral annulus (MA) was the earliest
atrial activation site (EAAS; 5 o'clock), AT was ablated not at the
EAAS, but at the tricuspid annulus (TA; 4 o'clock), 24ms later than the
EAAS. We suggest that preferential conduction from the TA to the EAAS of
the MA may be involved in AT.

\textbf{Keywords} : atrioventricular annulus atrial tachycardia,
adenosine triphosphate sensitive, radiofrequency ablation, coronary
sinus musculature, preferential conduction

\textbf{Introduction} : Atrial tachycardia (AT) at the atrioventricular
annulus (AVA) is reentrant and sensitive to adenosine triphosphate
(ATP).\textsuperscript{1} AT is usually ablated at the earliest atrial
activation site (EAAS); however, AVA-AT can be ablated at the
ipsilateral annulus far from the EAAS.\textsuperscript{2} We report AT
originating from the mitral annulus (MA) ablated at the tricuspid
annulus (TA).

\textbf{Case} : A 57-year-old man with repetitive supraventricular
tachycardia (SVT) was referred to our institution. P-wave morphology was
negative in leads II, III, aVF, and V6, and positive in lead V1 (Figure
1A). After obtaining written informed consent, catheter ablation was
performed.

Two decapolar and two quadripolar electrode catheters were positioned at
the coronary sinus (CS), His bundle, high right atrium (HRA), and right
ventricular apex, respectively. Programmed stimulation induced SVT
(Figure 1B), which was sustained during isoproterenol infusion.
Tachycardia cycle length (TCL) fluctuated from 370 to 390ms. The EAAS
was CS7/8 (MA 5 o'clock). The ventricular response was sometimes lost
without tachycardia termination. Dual atrioventricular (AV) nodal
physiology and ventriculoatrial (VA) conduction were not observed. VA
linking was not demonstrated in the HRA (288ms), distal CS (254ms), or
proximal CS (CSp; 218ms) by 360ms pacing; thus, AT originating from the
MA was suspected. Moreover, each return cycle after a single
extra-stimulus from the HRA at induction was longer than AV decremental
conduction delay. SVT was terminated by ATP (5mg bolus) with a prolonged
TCL; however, the atrio-his interval was unchanged, suggesting
ATP-sensitive reentrant AT.

Left atrium (LA) was mapped using the CARTO\selectlanguage{ngerman}\textsuperscript{®} system
(Biosense Webster, Diamond Bar, CA, USA) with
PentaRay\textsuperscript{®} catheter (Biosense Webster). The EAAS was
the MA (5 o'clock). Local activation of the ablation catheter was 8ms
delay at the earliest MA site and was just simultaneous at the inside CS
(Figure 2A and 2B), but SVT was not terminated for Radiofrequency (RF)
ablation at these sites. Then, the RA around CS ostium was mapped. The
earliest TA activation site (4 o'clock) was 24ms later than the EAAS
(Figure 2C); however, AT terminated 1.9s after RF delivery (Figure 2D).
After ablation, AT did not recur over 1 year. CARTO and fluoroscopic
views at the successful site are shown in Figure 2E. This site was far
from the CS ostium. The distance from the EAAS of MA to the successful
site was 27.9mm.

\textbf{Discussion} : This reentrant AT had slow conduction with a
decremental property resembling the AV node, and was ablated at the TA.
We speculated the mechanism of the AT.

Horie et al. reported 3 of 7 cases of ATP-sensitive AT from CSp were
ablated not the EAAS but the slow pathway area.\textsuperscript{3} These
cases may have had reentrant circuit involved perinodal tissue around
rightward/leftward posterior AV nodal extensions, and after the EAAS
ablation, CL was prolonged and the earliest site was changed to the CS
ostium. However, our case was not observed.

The mechanism of the AT was revealed by the post-pacing interval (PPI).
The PPI from CSp was similar to TCL and atrial activation sequence
during pacing resembled AT, but the PPI from EAAS was not (Figures
3A,3B). The CSp was close to the exit of reentrant circuit. Furthermore,
the success site had a 24ms delay from the EAAS. PPI was not evaluated
at the success site; however, this site may be the entrance of slow
conduction in the circuit and the circuit extended along posterior TA to
the CSp. Moreover, Chauvin et al. described the anatomical/histological
features of inferior RA to LA myocardial striated muscle connections
around the CS.\textsuperscript{4} We speculate that the reentrant
circuit was connected between the reentrant circuit and the EAAS by CS
musculature, leading to preferential conduction (Figure 3C).

In conclusion, ATP-sensitive AT originating from MA was successfully
ablated at the TA. TA ablation around the CSp should be considered when
ablation at MA and inside CS is ineffective.

\textbf{Conflict of interest and funding:} All the authors have no
conflicts of interest and funding.

\textbf{Author contributions:} Writing: Original draft (RT), formal
analysis (RT, NH, YM), validation (GM, MM, RT, MO, TK, KT), supervision
(AF).

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Matsuoka K, Kasai A, Fujii E, Omichi C, Okubo S, Teramura S, et al.
  Electrophysiological features of atrial tachycardia arising from the
  atrioventricular annulus. Pacing Clin Electrophysiol.2002;25:440-445.
\item
  Yamabe H, Okumura K, Koyama J, Kanazawa H, Hoshiyama T, Ogawa H.
  Demonstration of anatomic reentrant circuit in verapamil-sensitive
  atrial tachycardia originating from the atrioventricular annulus other
  than the vicinity of the atrioventricular node. Am J
  Cardiol.2014;113:1822-1828.
\item
  Horie T, Miyauchi Y, Kobayashi Y, Iwasaki YK, Maruyama M, Katoh T,
  Takano T. Adenosine-sensitive atrial tachycardia originating from the
  proximal coronary sinus. Heart Rhythm.2005;2:1301-1308.
\item
  Chauvin M, Shah DC, Haïssaguerre M, Marcellin L, Brechenmacher C. The
  anatomic basis of connections between the coronary sinus musculature
  and the left atrium in humans. Circulation. 2000;101:647-652.
\end{enumerate}

\textbf{Figure legends}

\textbf{Figure 1} . A: Twelve-lead ECG. B: Intracardiac electrogram
during SVT without isoproterenol. The earliest atrial activation site
(EAAS) was CS 7/8 (black arrow). HRA: high right atrium, His:
His-recording site, CS: coronary sinus, RVA: right ventricular apex,
EAAS: earliest atrial activation site.

Figure 2. A, B: Intracardiac electrograms and fluoroscopic views at
unsuccessful site. A: Mitral annulus. Focal activation was 8ms delay
from earliest atrial activation site (EAAS). B: Inside CS. Focal
activation was simultaneous from EAAS. C, D: Intracardiac electrogram at
successful tricuspid annulus site; C: Before ablation. Focal activation
was 24ms delay from EAAS. D: Ablation. Atrial tachycardia terminated
1.9s. E: Activation map and fluoroscopic view at the successful site.
The success site was far from the EAAS. HRA: high right atrium, His:
His-recording site, Nav: ablation catheter electrogram, CS: coronary
sinus, RVA: right ventricular apex, EAAS: earliest atrial activation
site, ABL: ablation catheter, AP: anteroposterior.

\textbf{Figure 3} . A, B: Post-pacing interval (PPI) at the CS proximal
(CSp) and the earliest atrial activation site (EAAS). A: PPI at CSp was
similar to tachycardia cycle length (TCL), and intra-atrial activation
sequence resembled atrial tachycardia. The last pace was orthodromic
conduction for CS7/8 (red dashed arrow). B: PPI at EAAS. PPI was not
similar to TCL and the last pace was antidromic (blue dashed arrows). C:
Presumed reentrant circuit and preferential conduction. HRA: high right
atrium, His: His-recording site, CS(M): coronary sinus (musculature),
RVA: right ventricular apex, PENT: PentaRay\textsuperscript{®} catheter,
LAO: left anterior oblique, EAAS: earliest atrial activation site,
CSp/d: proximal/distal CS, SCA: slow conduction area, PPI: post-pacing
interval, TA: tricuspid annulus.

\textbf{Figure (Figure 1: top, Figure 2: middle, Figure 3: bottom)}\selectlanguage{english}
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