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 Table of Contents  
Year : 2021  |  Volume : 6  |  Issue : 2  |  Page : 98-100

Demonstration of double-wave-like reentry using activation and propagation map in a patient with atrial flutter and previous atrial septal defect surgery: A case report

1 Section of Electrophysiology, McLaren Greater Lansing Hospital, Lansing, USA
2 Internal Medicine, Central Michigan University College of Medicine East Campus, Saginaw, MI, USA
3 Department of Cardiology, Walter Reed National Military Medical Center, Bethesda, MD, USA

Date of Submission19-Jun-2021
Date of Decision05-Jul-2021
Date of Acceptance08-Jul-2021
Date of Web Publication28-Dec-2021

Correspondence Address:
Dr. Khalil Kanjwal
McLaren Greater Lansing, Lansing, MI
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhr.ijhr_9_21

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Three-dimensional electroanatomic maps have revolutionized the management of complex arrhythmia. By providing a visual display of various arrhythmia mechanisms these maps have not only helped with the mechanism of the tachycardia but also allowed for precise localization of the critical isthmus. Herein, we present an interesting propagation map of a 55-year-old female with scar-related right-sided atrial flutter. The propagation map helped in localizing the critical isthmus and subsequent successful ablation.

Keywords: Ablation, activation map, case report, flutter, reentry, three-dimensional map

How to cite this article:
Kanjwal K, Kichloo A, Haji AQ. Demonstration of double-wave-like reentry using activation and propagation map in a patient with atrial flutter and previous atrial septal defect surgery: A case report. Int J Heart Rhythm 2021;6:98-100

How to cite this URL:
Kanjwal K, Kichloo A, Haji AQ. Demonstration of double-wave-like reentry using activation and propagation map in a patient with atrial flutter and previous atrial septal defect surgery: A case report. Int J Heart Rhythm [serial online] 2021 [cited 2022 Jul 2];6:98-100. Available from: https://www.ijhronline.org/text.asp?2021/6/2/98/334124

  Introduction Top

Complex atrial arrhythmias are usually seen after atrial fibrillation ablation and following cardiac surgery. These arrhythmias are usually scar-related and can be challenging to map and ablate. Three-dimensional (3D) electroanatomic mapping (EAM) has revolutionized both understanding and management of these arrhythmias.[1] EAM mapping along with activation and propagation maps have revolutionized the management of these arrhythmias. These maps can accurately localize the critical isthmus for successful ablation.[2] In this report, we attempt to present a visual display of double-wave-like reentry in a patient with atrial flutter and prior atrial septal defect (ASD) repair.

  Case Report Top

A 55-year-old female with a history of hypertension, diabetes, and prior history of ASD repair was seen in our arrhythmia office for palpitations. Her electrocardiogram (ECG) [Figure 1] in our office showed atrial flutter with negative p waves in leads 2, 3, and aVF. These features were suggestive of right-sided atrial flutter. The patient had multiple cardioversions in the past and she was highly symptomatic when in atrial flutter. She has been on amiodarone as well. She was offered electrophysiology study. The patient was brought to the electrophysiology laboratory in fasting state.
Figure 1: Baseline electrocardiogram should atrial flutter with negative p waves in inferior leads (arrows)

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After advancing catheters into various cardiac chambers atrial tachycardia with 2:1 AV conduction was noted with proximal to distal coronary sinus activation. The atrial tachycardia cycle length was 280 ms. Entrainment in cavotricuspid isthmus (CTI) revealed a long post pacing interval and tachycardia cycle length difference (80 ms). Thus, making CTI unlikely a part of the circuit.

It was decided to perform an extensive 3D map along with the activation and propagation map of the right atrium. Extensive mapping revealed scarring in the posterior and anterolateral parts of the right atrium. There were two areas of the scar noted in the anterolateral right atrium [Figure 2].
Figure 2: Voltage and activation map shows scarring in anterolateral area and posterior right atrium. The area of late activation and slow conduction is noted between lower scar and inferior vena cava (black open arrow)

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In addition, the activation map and propagation revealed that there was an area between the lower scar and the inferior vena cava (IVC) where the wavefront was propagating very slowly (slow zone) and after emerging from the area the wavefront divided into two. One wavefront propagated along the roof in the clockwise direction across the tricuspid valve and then back to the area where it emerged from. The second wavefront propagated inferiorly around the posterior right atrial wall, around the IVC, and back into the area. The two wavefronts used a common loop and behaved like a double-wave reentry (DWR) [Figure 3] and [Additional Video 1]

. There were also complex fractionated potentials noted in the slow zone and ablation in this area [Figure 4] terminated the tachycardia. The entrainment during tachycardia at successful site could not capture the atrium. After the tachycardia was terminated an ablation line was extended from the scar to the IVC to create a line of the block. The patient was started on high dose of isoproterenol. Both programmed stimulation and burst pacing failed to induce any tachycardia.
Figure 3: Activation map and voltage map showing propagation and double wave reentry created by a common loop between the lower and inferior vena cava and scar posteriorly in the right atrium. Both wave fronts are using common loop. One wavefront propagated along the roof in the clockwise direction across the tricuspid valve and the back to the area where it emerged from. The second wave front propagated inferiorly around the posterior right atrial wall, around the inferior vena cava and back into the area, the white and black arrow depicts the propagation in the complex circuit

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Figure 4: Ablation around slow zone resulted in termination of the flutter. Both wave fronts used a common critical isthmus and the flutter terminated

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The patient was seen in the clinic and at 6 months been doing well without any recurrences.

The ethical approval and written consent were waived by the institutional review board of our hospital owing to the retrospective nature of the study.

  Discussion Top

Typical right atrial flutter in humans is an example of single-loop reentry and successful ablation of the vulnerable “isthmus” is well known.[1],[2] Double-loop macroreentrant tachycardia has been a well-recognized entity even before the advent of 3D mapping. The 3D mapping has more clearly defined the wavefront and vastly increased our understanding of the mechanism of this unique tachycardia.[3] Shah et al.[4] described the first such series of dual-loop intra-atrial reentry in humans using Biosense 3D mapping.

The usual mechanism, particularly in the right atrium involved an area of conduction block such as an atriotomy scar from a prior surgical instrumentation such a post coronary bypass surgery or repair of ASD. 3D mapping helps demonstrate the simultaneous coexistence of both loops. However, visual interpretation of these activation patterns seen on static propagation maps is limited and can be missed easily. Interruption of one loop of the tachycardia usually does not affect the other loop and uninterrupted atrial activation continues in the other loop, however, ECG transformation is instantaneous and without an intervening pause.[4] El-Sherif et al.[5] in figure-8 reentry in a canine ventricular model postinfarction, showed that the novel mechanism of transformation of a reentrant tachycardia ECG may be considered the gold standard test for a true figure-8 reentry circuit in which the remaining loop is capable of independent stability as opposed to a figure-8 activation pattern.

In our case report, the patient had two distinct scars along the lateral right atrium and the larger macroreentrant loop was noted to propagate around the larger scar identified superior to the smaller inferior scar. A distinct isthmus is a characteristic feature of such double loop reentrant tachycardia, typically where the two wavefronts collide and can be a suitable site for successful ablation. Location of this so-called isthmus may play a role in successful ablation in this area and adequate contact and reasonable stability of the ablation catheter dictates the success of ablation as was noted in this report. Several linear lines of block may be needed to target both loops for successful ablation. In previous reports, ablation in the critical isthmus was rarely successful[1] and our case report is unique in that one ablation lesion terminated the tachycardia indicating that the critical isthmus was narrow and allowed adequate stability and catheter contact.

DWR involves two independent waves propagating in the same circuit at the same time, doubling the rate of atrial or ventricular activation. The current 3D electro-anatomical systems are incapable of mapping DWR because these maps fail to register the true cycle length which is double than what is recorded, and that there are two instead of one activation to be annotated.[6] Thus, in these situations, a propagation map may provide the visual display of DWR.[6]

The recent upgrades in the mapping system which involve coherence and ripple maps from Carto Biosense may allow for a better visualization and understanding of the DWR.

There a few teaching points from this case we report. One should anticipate complex mechanisms such as a double-loop macroreentry in patients with prior history of surgical instrumentation of the right atrium. Sometimes identification of a critical isthmus, using 3D propagation mapping and voltage mapping, where the two wavefronts from the double loop collide can be a suitable target for successful ablation. Ablation success can be long lasting and gratifying in such cases.

  Conclusion Top

Atrial flutter or tachycardia can have a critical isthmus and the propagation and activation map may allow for identification and successful ablation of these complex scar-related tachycardia.

Institutional review board statement

The ethical approval was waived by the institutional review board of our hospital because of this being a single case report.

Declaration of patient consent

The authors certify that they have obtained the appropriate consent form from the patient. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal her identity.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Additional file

Additional Video 1: Propagation and activation map showing DWR using a common area of slow zone between lower scar and IVC. One wavefront propagated along the roof in the clockwise direction across the tricuspid valve and the back to the area where it emerged from. The second wave front propagated inferiorly around the posterior right atrial wall, around the IVC and back into the area.

  References Top

Cosio FG, López-Gil M, Goicolea A, Arribas F, Barroso JL. Radiofrequency ablation of the inferior vena cava-tricuspid valve isthmus in common atrial flutter. Am J Cardiol 1993;71:705-9.  Back to cited text no. 1
Feld GK, Fleck RP, Chen PS, Boyce K, Bahnson TD, Stein JB, et al. Radiofrequency catheter ablation for the treatment of human type 1 atrial flutter. Identification of a critical zone in the reentrant circuit by endocardial mapping techniques. Circulation 1992;86:1233-40.  Back to cited text no. 2
Shah D, Jaïs P, Takahashi A, Hocini M, Peng JT, Clementy J, et al. Dual-loop intra-atrial reentry in humans. Circulation 2000;101:631-9.  Back to cited text no. 3
Shah DC, Jaïs P, Haïssaguerre M, Chouairi S, Takahashi A, Hocini M, et al. Three-dimensional mapping of the common atrial flutter circuit in the right atrium. Circulation 1997;96:3904-12.  Back to cited text no. 4
El-Sherif N, Mehra R, Gough WB, Zeiler RH. Reentrant ventricular arrhythmias in the late myocardial infarction period. Interruption of reentrant circuits by cryothermal techniques. Circulation 1983;68:644-56.  Back to cited text no. 5
Maury P, Tabuteau M, Mandel F, Delasnerie H, Beneyto M, Voglimacci-Stephanopoli Q, et al. First three-dimensional documentation of double-wave reentry in humans. HeartRhythm Case Rep 2021;7:374-7.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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