184

Transcristal Conduction During Isthmus Ablation of Typical

Atrial Flutter: Influence on Success Criteria
ERIC

M.D., SANA OUALI, M.D.,

FRED
ANSELME, M.D., ARNAUD SAVOURE,
ALAIN CRIBIER, M.D., and NADIR SAOUDI, M.D.
From the Cardiology Department, Rouen University Hospital, Rouen, France; and Princess Grace Hospital,
Cardiology Department, Monaco

Introduction
The crista terminalis (CT) has been recognized as the
anatomic structure responsible for the line of conduction
block at the posterior right atrial wall during typical atrial
flutter.1 It is now well established that this line of block is
mainly functional.2-4 Transverse conduction across the CT
can be observed at long pacing cycle length or during some
atrial arrhythmias, such as lower loop reentrant tachycardia.5
During typical atrial flutter ablation, determination of
complete clockwise isthmus block most often is based on
the recording of a purely craniocaudal activation sequence
at the anteroinferior right atrium (AIRA) while pacing the
proximal coronary sinus (pCS).6,7 However, rapid transverse
conduction across the CT can modify the activation sequence
at the AIRA and masquerade as persistent residual clockwise
isthmus conduction.4
The aims of this study were to evaluate (1) the incidence
of transverse conduction across the CT, (2) the influence of
transcristal conduction on AIRA activation sequence during
pCS pacing after isthmus block,completion and (3) the effectiveness of a dynamic pacing technique (positional pacing)
in discriminating anterior from posterior low right atrial conduction properties during typical atrial flutter ablation.
Methods
Study Population
Fifty-five consecutive patients (47 men and 8 women;
mean age 65 10 years) with recurrent (45%) and/or highly
symptomatic typical atrial flutter with inferior vena cava
tricuspid annulus isthmus demonstrated by entrainment maneuvers to be part of the tachycardia circuit8 were included
in the study. Atrial flutter was present for a mean of 19 26
months despite the use of 1.3 0.8 antiarrhythmic medications, including amiodarone in 38 patients.
Ablation Procedure
Patients were studied in the postabsorptive state. All antiarrhythmic drugs except amiodarone had been stopped for
at least 5 drug half-lives. A multipolar halo catheter (Irvine

J Cardiovasc Electrophysiol, Vol. 15, pp. 184-189, February 2004.

Address for correspondence: Frederic Anselme, M.D., Rouen University
Hospital, Cardiology department, 1 rue de Germont, 76031 Rouen, France.
Fax: 33-02-32-88-81-23; E-mail: Frederic.anselme@chu-rouen.fr
Manuscript received 29 September 2003; Accepted for publication
8 October.
doi: 10.1046/j.1540-8167.2004.03430.x

Biomedical Inc., Irvine, CA, USA) with the distal bipole located close to the anterior lip of the ablation line was used
to record the right atrial activation sequence around the tricuspid annulus (Fig. 1). Its anterior location, close to the
tricuspid ring, was checked in the right anterior oblique view
in all patients. A multipolar catheter was inserted within the
coronary sinus with the proximal bipole located at its ostium. In patients who were in sinus rhythm at the start of the
study (n = 25), ablation was performed during permanent
pCS pacing. In the remaining patients (n = 30), ablation was
performed during ongoing atrial flutter and pursued (if required) during pCS pacing after restoration of sinus rhythm.
The ablation catheter, which had an 8-mm-tip, was placed
close to the ventricle within the isthmus, approximately 2 to
3 cm away from the CS ostium. Stepwise withdrawal of the
ablation catheter was performed during radiofrequency delivery. The ablation line orientation was regularly controlled
using fluoroscopic images in left anterior oblique view and
was straight posterior. The radiofrequency generator (Irvine
Biomedical Inc.) was preset to deliver up to 100 W, with a
target temperature of 70 C.
Positional pacing was performed when, after radiofrequency energy delivery, a clear and significant modification
of the AIRA activation sequence suggested the presence of
complete isthmus block during pCS pacing. This technique
consisted of pacing successively at the pCS, the posterior lip
of the ablation line (PL), and the posteroinferior right interatrial wall (PW), at the same (long) cycle length (Fig. 1).
Incremental pCS pacing was not used to differentiate true
incomplete isthmus block from transverse conduction across
the CT, because rate-dependent conduction block can occur
at both the isthmus and the CT. Mapping only the AIRA,
modification of the AIRA sequence during fast pCS pacing
would have been difficult to interpret.
Definitions
Complete clockwise isthmus block: Lengthening of the
interval between the stimulation artifact and the atrial potential recorded at the distal halo bipole (S-AH1-2) and/or
modification of AIRA activation sequence during PL pacing compared to pCS pacing at identical pacing cycle length
(600 ms; Fig. 2A and 2B).
CT transverse conduction: Shortening of the S-AH1-2 interval and/or modification of AIRA activation sequence during PW pacing compared to pCS pacing at identical pacing
cycle length (600 ms; Fig. 2C and 2D).
Statistical Analysis
Results are expressed as mean SD. Analysis of variance
and unpaired t-test were used for comparison. P < 0.05 was
considered statistically significant.

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185

Intra-Atrial Conduction Time and Transcristal

Conduction Properties
In patients with transverse conduction across the CT and
complete isthmus block, for a given site of stimulation (pCS,
PL, or PW), S-AH1-2 intervals were not significantly different as a function of AIRA activation pattern during pCS
pacing (Fig. 4A).
Conversely, S-AH1-2 intervals were significantly shorter
during PW pacing and pCS pacing in patients with transcristal
conduction compared to patients without. Of interest, this
interval was similar in patients with and without transverse
conduction across the CT during PL pacing (Fig. 4B).
Final Ablation Results
Figure 1. Schematic representation of the right atrium and selected key
anatomic structures in left anterior oblique (LAO) view. The distal part of
the halo catheter is positioned within the anteroinferior right atrium (AIRA).
Activation is pictured during proximal coronary sinus pacing in the absence
of transcristal conduction. Sites where positional pacing is performed are
shown. CS = coronary sinus; IVC = inferior vena cava; PL = posterior lip
of the ablation line; PW = posteroinferior right atrial wall; SVC = superior
vena cava.

Results
Patient and procedural data are given in Tables 1 and 2,
respectively.
AIRA Patterns of Activation During pCS Pacing
After significant and often abrupt modification of the
AIRA activation sequence during pCS pacing, three AIRA
patterns of activation could be described.
1.
2.

3.

A purely and gradually descending AIRA activation sequence, which we called type A (Fig. 3A), was observed
in 29 patients
An AIRA sequence of depolarization, with synchronous
activation at several adjacent halo bipoles, with the distal bipole activated the last, which we called type B
(Fig. 3B), was observed in 10 patients
An AIRA activation sequence suggesting incomplete
isthmus block, with the distal halo bipole activated simultaneously or earlier than more proximal bipoles,
which we called type C (Fig. 3C), was observed in 16
patients.

According to our definitions, positional pacing allowed

identification of true incomplete isthmus block in 4 patients
with an initial AIRA pattern of type C. In the overall population, transverse conduction across the CT was observed in
47 patients (85%) during PW pacing. In patients with type A
AIRA activation pattern, shortening of S-AH1-2 associated
with modification of the AIRA sequence of activation during
PW pacing was required to diagnose transverse conduction
across the CT. Among the patients with transcristal conduction and complete clockwise isthmus block (46 patients), an
AIRA pattern of activation of type A, B, and C was observed
in 21, 10, and 15 patients, respectively. In patients with confirmed complete isthmus block, AIRA activation sequences
of type B and C during pCS pacing were thought to be related
to CT transverse conduction.

In all patients with type A AIRA pattern of activation,

bidirectional complete isthmus block was confirmed during
PL and AIRA pacing. Among 26 of 55 patients with atypical AIRA activation sequence (types B and C) during pCS
pacing, PL pacing led to S-AH1-2 interval lengthening in
22, which demonstrated complete clockwise isthmus block.
In these patients, AIRA pacing confirmed counterclockwise
isthmus block and, therefore, the success of the ablation procedure. In the remaining 4 patients with incomplete isthmus
block, the ablation procedure guided by the positional pacing
technique was continued until achievement of complete isthmus block, within the same session in 2 patients. In the other
2 patients, complete isthmus block could not be achieved because of a wide subeustachian isthmus pouch in which very
low blood flow prevented sufficient power delivery with a
regular 8-mm catheter in 1 patient and because of a prominent eustachian crest in the other patient. These patients were
treated successfully with a second radiofrequency ablation
session using a cooled-tip ablation catheter. In all of the patients, positional pacing promptly and accurately identified
isthmus line conduction properties during ablation.
Clinical Follow-Up
During a mean follow-up of 20 7 months (range 14
37), none of the patients experienced clinical atrial flutter
recurrence. Atrial fibrillation was observed in 1 of 8 patients
without transverse CT conduction and in 15 of 47 patients
with transverse CT conduction (P = ns).
Discussion
Conduction Across the CT
Using a simple dynamic pacing technique, transverse conduction across the CT has been identified at a slow pacing
cycle length in the vast majority of patients (85%) suffering
from typical atrial flutter. This was in accordance with the
study by Arenal et al.,2 who reported that only 4 (18%) of 22
patients had CT block during PW pacing at 600 ms. Although
incomplete isthmus block pattern due to transcristal conduction has been recognized using several multipolar catheters,
the real incidence of this phenomenon is unknown. In our
series, a false aspect of isthmus conduction block (AIRA
activation sequence of type C) related to transcristal conduction was observed in one third of the patients during pCS
pacing. In these patients, PL pacing allowed rapid identification of complete clockwise isthmus block and consequently
led to avoidance of unnecessary additional radiofrequency

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Vol. 15, No. 2, February 2004

Figure 2. Role of positional pacing in the assessment of isthmus and crista terminalis (CT) conduction properties. Tracings are associated with a schematic
representation of the right atrium (as in Fig. 1) depicting the corresponding activation wavefront. A: Example of anteroinferior right atrium (AIRA) activation
pattern suggesting incomplete isthmus block during proximal coronary sinus (pCS) pacing (left). The distal halo bipole is clearly depolarized before more
proximal halo bipoles. Posterior lip of the ablation line (PL) pacing (right) led to both an increase in S-AH1-2 interval duration and a modification of the AIRA
activation sequence, which indicated the presence of complete clockwise isthmus block. B: Purely descending AIRA activation sequence during pCS pacing
(left). PL pacing confirmed the presence of complete clockwise isthmus block (right). C: AIRA activation pattern suggesting collision between a clockwise
and a counterclockwise activation wavefront during pCS pacing (left). Notice that double potentials are not parallel, with a shorter interpotential interval
duration at the Abl p close to the inferior vena cava. These observations suggest incomplete isthmus block, whereas PL pacing confirmed complete clockwise
isthmus block (not shown). Posteroinferior right interatrial wall (PW) pacing led to both a shortening of S-AH1-2 interval and a modification of the AIRA
activation sequence, which support the presence of transverse conduction across the CT. D: Purely descending AIRA activation sequence is observed during
pCS pacing (left). PW pacing revealed the presence of transverse conduction across the CT (right). H19-20 to H1-2 = proximal to distal halo bipoles; Abl
d, m, p = distal, mid, and proximal ablation bipoles, respectively.

delivery. During PW pacing, a frank shortening of S-AH1-2

interval associated with modification of the AIRA activation
sequence was systematically observed, suggesting conduction at the inferior part of the CT (Fig. 2C). In 10 patients

with complete isthmus block, the AIRA activation sequence

was not gradually descending during pCS pacing. Several adjacent halo bipoles were activated simultaneously, with the
distal bipole depolarized last (AIRA activation sequence of

Anselme et al.

TABLE 1
Patient Characteristics
Male/female
Age (years)
Heart disease (patients)
History of atrial fibrillation
AF1 duration prior to ablation (months)
Antiarrhythmic drugs
Mean no. of antiarrhythmic drugs per patient
Amiodarone
History of cardioversion for AFL
Rhythm at start (SR/AFL)

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187

TABLE 2
Procedural Parameters
47/8
65 10
18 (33%)
26 (47%)
19 (0.5120)
48 (87%)
1.3 0.8 (03)
38 (69%)
30 (55%)
25/30

Values are given as number of patients, unless otherwise indicated.

AFL = typical atrial flutter; SR = sinus rhythm.

type B). In all of these patients, complete clockwise isthmus

block was demonstrated during PL, and a frank shortening of
S-AH1-2 associated with little or no modification of AIRA
activation sequence was observed during PW pacing. This
suggested conduction across the upper part of the CT.
Dynamic Pacing Techniques in Determination
of Isthmus Block Completion
Other dynamic pacing maneuvers have been described to
identify complete isthmus block in difficult cases. Differential pacing consists of sequential pacing at the AIRA close
and remote from the isthmus ablation line.9 This technique
has been found to be efficient in discriminating residual slow
isthmus conduction from true isthmus block, even if multicomponent potentials are recorded on the ablation line. In the

Success rate
Procedure time (min)
Fluoroscopy time (min)
No. of pulses
Duration of radiofrequency energy delivery (s)

53/55
88 25
16 7
54
655 615

study by Shah et al.,9 the potential role of transcristal conduction was not specifically evaluated. However, it is likely
that the presence of transverse conduction across the CT reducing the activation time to the opposite ablation lip would
increase the rate of false-positive results and therefore decrease the specificity of this technique. Dynamic pacing also
was used in the study by Chen et al.10 to determine isthmus
block completion. The same principle as differential pacing
was applied on the septal side of the ablation line. However,
in this technique the His-bundle area and the CS ostium were
chosen as the pacing sites but were remote from the ablation
line. As a consequence, (1) slow residual isthmus conduction
can be unrecognized, and (2) false diagnosis of incomplete
isthmus block can be made in patients with transcristal conduction (i.e., patients with type C AIRA activation pattern
during pCS pacing).
Potential Mechanisms for Transcristal Conduction
to Influence AIRA Activation Sequence
We have shown that the conduction times between PL,
pCS, and PW stimulation sites and the atrial electrogram

Figure 3. Types of anteroinferior right atrium (AIRA) activation pattern during proximal coronary sinus (pCS) pacing. Tracings are associated with a
schematic representation of the right atrium (as in Fig. 1) depicting the corresponding activation wavefront. Type A AIRA activation pattern (left): Purely
and gradually descending AIRA activation sequence during pCS pacing. Type B AIRA activation pattern (middle): Synchronous atrial activation at several
adjacent halo bipoles, with the distal bipole activated the last during pCS pacing. Type C AIRA activation pattern (right): Distal halo bipole is activated
simultaneously or earlier than more proximal bipoles, suggesting incomplete isthmus block.

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Figure 4. S-AH1-2 interval duration measurements as a function of the

pacing site, in patients with complete isthmus block. A: S-AH1-2 intervals
in with type A, B, or C anteroinferior right atrium (AIRA) activation pattern
during (pCS) pacing, measured during each pacing protocol. B: S-AH1-2
intervals in patients with (CTTC+) and without (CTTC) CT transverse
conduction, measured during each pacing protocol.

recorded at the distal halo catheter were similar irrespective of

the pattern of AIRA activation sequence during pCS pacing.
The influence of transcristal conduction on AIRA activation
sequence during pCS pacing most likely was due to the relative difference between the conduction time across the CT
and that of the muscular fibers in the vicinity of the tricuspid
annulus rather than related to a particularly fast transverse
conduction across the CT. The complexity of the muscular
architecture around the CS ostium and its associated nonuniform anisotropic conduction11,12 could be one explanation
for this phenomenon. A favorable fiber orientation around
the CS ostium would make the posterior route (across the
CT) preferential during pCS pacing.
As expected, S-AH1-2 intervals were significantly shorter
during pCS and PW pacing in patients with transcristal conduction compared to patients without, but no difference was
found between the two patient groups during PL pacing.
Because PL pacing almost eliminated the influence of transcristal conduction on AIRA activation time, it appeared to
be the best pacing site to optimize evaluation of isthmus conduction properties.
Study Limitations
On-site recording of parallel and widely spaced double
potentials all along the ablation line can be used to determine
isthmus block completion after catheter ablation of atrial flutter.13 However, as we have previously shown,14 both falsepositive and false-negative cases can be encountered using
only this technique. False-negative results can be seen with
conduction across the inferior part of the CT. In this case,
double potentials frequently are not parallel, with an interpotential interval shorter in the vicinity of the inferior vena cava
(Fig. 2C). For example, in our study, the interpotential interval

Figure 5. Diagnosis of true incomplete isthmus block by posterior lip of the

ablation line (PL) pacing. A: During proximal coronary sinus (pCS) pacing,
type C anteroinferior right atrium (AIRA) activation pattern is observed.
However, parallel and widely spaced double potentials are recorded along
the ablation line. Note that the H1-2 bipole straddled the ablation line and
also recorded a double potential. B: During PL pacing, there was a frank
modification of the AIRA activation sequence with shortening of S-AH1-2 interval, confirming incomplete isthmus block. C: Radiofrequency energy was
delivered during PL pacing at a site where double potentials were recorded.
This led to modification of the AIRA activation pattern and achievement of
complete clockwise isthmus block. Abbreviations as in Figure 2.

duration measured close to the inferior vena cava and close to

the tricuspid annulus were 80 18 and 109 23 ms, respectively (P < 0.001) during pCS pacing in patients with type
C AIRA activation pattern. In these patients, interpotential
intervals also were shorter posteriorly during AIRA pacing
(131 25 vs 120 27 ms, P < 0.01) but to a much lesser
degree. In addition, they were significantly wider than those
recorded during pCS pacing. These observations suggest either that conduction block across the CT has already occurred
at that pacing cycle length during AIRA pacing or that AIRA
pacing is less sensitive to transcristal conduction than pCS
pacing. Because Arenal et al. showed that conduction block
across the CT occurred at slower pacing rates from the posterior wall than from the AIRA, the former hypothesis is
unlikely. Conversely, AIRA pacing was performed at sites
closer to the ablation line compared to pCS pacing, which
could explain the little or no impact of transcristal conduction on isthmus conduction assessment during AIRA pacing.
In any case, the problem of potential unidirectional residual
isthmus conduction remains, and techniques such as positional pacing still would be helpful in evaluating clockwise
isthmus conduction. In the presence of parallel and widely
spaced double potentials, the question remains as to whether
a very slow conduction persists across the ablation line.
Figure 5 shows such a case where clear double potentials
are recorded along the ablation line with residual isthmus
conduction as confirmed by PL pacing and complete isthmus
block occurrence after an additional radiofrequency delivery.
S-AH1-2 interval duration was not systematically measured at baseline during pCS pacing. As a consequence,
we were not able to evaluate whether the percentage of

Anselme et al.

S-AH1-2 interval prolongation following ablation could predict the achievement of complete isthmus block.
Clinical Implications
In the setting of atrial flutter ablation, transcristal conduction is frequent at slow pacing cycle length and significantly
influences the AIRA activation sequence in half of the patients during pCS pacing. In up to one third of the patients,
transverse conduction across the CT modified the AIRA activation sequence during pCS pacing to such an extent that
it incorrectly suggests incomplete isthmus block. Pacing at
the posterior lip of the ablation line and at the posteroinferior right interatrial wall can readily identify the presence of
residual isthmus conduction and transverse conduction across
the CT, respectively. This technique should be considered a
useful routine tool among those used to determine success
during atrial flutter ablation.
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