Incremental His-to-coronary sinus maneuver: a nonlocal electrogram-based technique to assess complete cavotricuspid isthmus block during typical flutter ablation.

BACKGROUND: Achievement of complete cavotricuspid isthmus (CTI) conduction block reduces typical atrial flutter recurrences after ablation. The lack of increase in the His-to-coronary sinus ostium atrial interval during incremental pacing (IP) from the low lateral right atrium may distinguish slow conduction from complete CTI conduction block.

METHODS AND RESULTS: Sixty-six consecutive patients (age, 65±13 years; 18% female) were prospectively included. A <10 ms increase in the His-to-coronary sinus ostium atrial timing during low lateral right atrium IP at cycle length of 600 ms through 300 ms was compared with the previously reported IP maneuver for the confirmation of complete CTI block. On the basis of the IP maneuver, complete CTI block (phase 2) was achieved in 59 patients, in 13 of whom an intermediate phase of functional CTI block (phase 1) was observed. In the remaining 7 patients, the IP maneuver did not allow for assessment of complete CTI block because of the presence of inconclusive potentials in the CTI ablation line. As compared with the IP maneuver, the incremental His-to-coronary sinus ostium maneuver was consistent with functional CTI block during phase 1 in all cases and conclusive of complete CTI block in 98% of cases during phase 2.

CONCLUSIONS: The incremental His-to-coronary sinus ostium maneuver is analogous to the IP maneuver in distinguishing complete CTI block from persistent CTI conduction. This maneuver may provide confirmation of CTI block in those patients in whom assessment of local electrogram-based criteria is not feasible because of inconclusive potentials in the CTI ablation line.