Focal atrial tachycardia arising from the cavotricuspid isthmus with saw-tooth morphology on the surface ECG: Electrocardiographic and electrophysiologic characteristics

Background: Limited information is available about focal atrial tachycardia (AT) arising from cavotricuspid isthmus (CTI). Objective: The purpose of this study is to evaluate the electrocardiographic and electrophysiologic characteristics of a focal AT arising from the CTI. Methods: From a consecutive series of 92 patients undergoing radiofrequency catheter ablation (RFCA) for focal AT, three (4.4%) patients (three men) with a focal AT arising from the CTI were studied. Results: The median age was 71 years (range, 50 to 81 years). None of the patients had a history of CTIdependent atrial flutter. The electrocardiogram (ECG) of a focal AT showed a significant negative F-wave in the inferior leads. Focal AT could be reproducibly initiated and terminated with programmed stimulation. The focus of the tachycardia was localized to the central isthmus in two and the paraseptal isthmus in one patient. The median tachycardia cycle length was 275 ms (range, 260 to 310 ms). In two patients, the focal AT was adenosine insensitive. In all of the patients, tachycardia was entrained from multiple right atrial sites, including the earliest activation site. RFCA was acutely successful in all patients. Long-term success was achieved in all patients over the median follow-up of 18 months (range, 6 to 33 months). Conclusions: Cavotricuspid isthmus is an uncommon site of origin for focal AT. This focal AT has unique electrocardiographic characteristics such as saw-tooth morphology on ECG and is suggested to be caused by a focal reentrant circuit located at the CTI. Long-term success is achieved with focal ablation.