A Case of Successful Ablation of Postoperative Atrial Flutter with Pouch-Like Recesses Using Irrigated Tip Catheter

A 64-year-old man was referred to our hospital in October 2009 because of atypical atrial flutter (AFL). He had received the surgical repairment of atrial septal defect at 20-year-old. Electrophysiological study revealed that the activation sequence was cavotricuspid-isthmus-dependent and indicated the clockwise rotation around tricuspid valve annulus (TVA). Electro-anatomical mapping revealed that atrial incision was by-stander. Linear ablation to cavotricuspid-isthmus was unsuccessful because of enlargement of right atrium and temperature-rising leading to thrombogenesis and stream pop. Right atrial angiography performed before the second session revealed deep pouch-like recesses in mid-isthmus lesion. Large and sharp atrial potentials were recorded on the TVA side of the pouch. Point-by-point radiofrequent application on the both sides of TVA and inferior vena cava (IVC) of the pouch was performed under the sinus rhythm using 8 mm-irrigated tip catheter (30 W, 60 sec), and the bidirectional isthmus conduction block was completed. The irrigated tip catheter may give the effectiveness to the ablation on the pouch-like recesses such as our case.