Relation between transverse conduction capability and the anatomy of the crista terminalis in patients with atrial flutter and atrial fibrillation - Analysis by intracardiac echocardiography

Although crista terminalis (CT) has been identified as the barrier to transverse conduction during typical atrial flutter (AFL), the relation between transverse conduction capabilities and anatomy of the CT remains unclear. The aim of the study was to evaluate that relation using intracardiac echocardiography (ICE). Ten patients with typical AFL (group AFL), 7 patients with paroxysmal atrial fibrillation (PAF) (group AF) and 8 patients without PAF or AFL (group N) underwent electrophysiologic testing. Using ICE images, the maximum diameter of the short axis of the CT (dCT) was measured and mapping and pacing catheters were positioned precisely. From extrastimulation delivered 1-2 cm anteriorly (free wall) or posteriorly (posterior wall) to the CT, the effective refractory period (CT-ERP) was determined as the longest coupling interval that resulted in split potentials at the mapping catheter positioned along the CT, a finding consistent with a transverse conduction block at the CT. The dCT was greater in group AFL than in groups AF and N (5.0 +/- 0.8 vs 4.3 +/- 0.7, p<0.05 and 4.2 +/- 0.4 mm, p<0.01, respectively). The CT-ERP was longer during pacing from the posterior wall than from the free wall (307 +/- 68 vs 266 +/- 29 ms, p<0.05) as a whole group. The CT-ERP for the posterior wall pacing was longer in group AFL than in group N (339 +/- 80 vs 255 13, p<0.05). CT-ERP did not correlate with dCT; however, dCT was greater in patients with split potentials at the CT than in patients without them (4.9 +/- 0.8 vs 4.1 +/- 0.5 mm, p<0.05). Therefore, the transverse conduction block of CT was more likely to occur in a thick CT. A limited transverse conduction capability of the CT is related to its thickness and might contribute to the development of typical AFL.