July06, 2022,UK


Abstract Volume: 4 Issue: 1 ISSN:

Clinical Cases of Supraventricular Arrhythmia Related to Rooflines after AF Ablation

Dr M Belhameche PHD MD1, Dr N Zarouf MD2, Dr S Naccache MD3, Dr A Kovalchuk PHD MD4, Dr S Sioua MD5, PR Bouzelmat PHD MD6, Dr A Salhi PHD MD7

1,2,3,4,5,6,7. GHEF Marne le vallée Rhythmology Unit.

Corresponding Author: Dr M Belhameche, GHEF Marne le vallée Rhythmology Unit.

Copy Right: © 2022 Dr M Belhameche. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: January 04, 2022

Published Date: January 20, 2022




In the literature, left atrial flutter or tachycardia are more and more frequent due to the act of ablation of AF, in particular, persistent AF and that whatever the strategy.

We will describe 3 cases of recurrence related to gaps on the roof lines that were made on previous AF ablation.

One recurrence in the form of AF, and two recurrences in the form of atypical flutter.


All the patients were symptomatic.

They were able, to benefit from, general anesthesia, and a transesophageal ultrasound, which allowed us both to eliminate an intra-auricular thrombus and to perform the transseptal puncture safely.

We had used the Rythmia system from Boston scientific.

One decapolar catheter was positioned in the coronary sinus.

Left atrial geometry and computer matrix creation were performed using the INTELLAMAP ORION™, and ablation was performed with the INTELLAVMIFI OI™ ablation catheter.


Review the literature to try to understand the mechanisms and prevent them.

Abbreviations and Acronyms:

AF Atrial fibrillation,

AT atrial tachycardia,


LA Left atrial,

LAA Left atrial appendage,

MI Mitral isthmus, 

PV Pulmonary vein, 

HBP High blood pressure, 

NID Non-insulin-dependant diabetes, 

SAS Sleep apnea syndrome, 

BMI Body mass index, 

EHRA European heart association, 

CS coronary sinus, 

LVEF Left ventricular ejection fraction, 

LAS Left atrial size, 

IAS interatrial septum.

LV left ventricular, 

VC Vena cava

Clinical Cases of Supraventricular Arrhythmia Related to Rooflines after AF Ablation

First case:

We present the case of a 62 years-old man, which has as risk factors: hypertensive, non-insulin-dependent diabetic, patient sleep apnea syndrome, and a body mass index of 29. Undilated LV cardiac ultrasound with 55% LVEF and 22 cm2 OG size.With previous atrial fibrillation radiofrequency catheter ablation. He had undergone pulmonary vein (PV) isolation using RF and left atrial (LA) roof and mitral isthmus linear ablation for symptomatic and drug-resistant persistent atrial fibrillation (AF) in his first procedure 11 months earlier. He was referred for catheter ablation of a recurrent: 

Atrial fibrillation Symptomatic (level IIa B EHRA), and drugs refractory ( Beta-blocker and Flecainide). (30)

The patient consented to follow institutional guidelines.

The patient had returned to sinus rhythm after induction of anesthesia.

A left atrial (LA) map was done while pacing at 600 ms with the Intellanav Mifi OI catheter placed in the Left Atrial appendage (LAA).

This map showed Right PVs Reconnection, LSPV reconenction, a gap on the mitral isthmus and another gap in the roofline.

Figure: 1

  • Map 1: LAA Pacing, voltage map, First, the PVs have been disconnected and the mitral line has been blocked.
  • Activation Map 1 :a. Mitral isthmus passage + LSPV and MI ablation b. RPV ablation Finally, the gap on the roofline has been ablated.
  • Activation map 1 : a. Endocardial gap on the roofline b. ablation on the roofline gap.

A verification map has been done to check the roofline block in pacing (600 ms) from LAA. This map shows an endocardial line of the block with double potentials all along the line.

However, we can clearly see on the activation map a breakthrough from the other side of the line, at the posterolateral wall by the region of the Bachmann bundle (or septopulmonary bundle ?). This is a sign of an epicardial bridge over the roofline.

Figure: 2

  • Activation Map 2 : a. endorectal roof line blocked + breakthrough b. Epicardial passage. RF ablation has been done on this breakthrough.
  • Activation map 2: ablation on the breakthrough.
  • Activation Map 2 : epicardial breakthrough / b. Activation Map 3 : no more passage through the roofline.

The procedure lasted 125 min (ablation time 90 min, fluoroscopy 15 min),

The Bachmann bundle is an important anatomic structure that may be resistant to transmural ablation and can function as an epicardial bridge across the anterior wall of the left atrium

We report a case of AT with epicardial bridging over a previously blocked endocardial anterior linear lesion set.

Second case:

62-year-old patient as a risk factor for hypertension, dyslipidemia, stable coronary insufficiency and treated dysthyroidism hospitalized for an attack of heart failure:

NYHA III stage dyspnea, blood pressure 110/60 mmHg, HR 13O / min O2 saturation at 92% under 5L/O2. The ECG showed atypical flutter with HR of about 130 / min. its treatment includes ACE inhibitors, beta-blockers as well, DOA and Aldactone. Cardiac ultrasound showed undilated LV with overall hypokinesia and an estimated LVEF of 45%. The size of the LA was measured at 25 cm2

This patient had undergone AF ablation one year ago. The ablation procedure consisted of isolating the VPs, a line from the roof and a line on the mitral isthmus. The ablation procedure consisted of isolating the VPs, a line from the roof and a line on the mitral isthmus. The patient consented to following institutional guidelines.

He was referred for catheter ablation of a recurrent “symptomatic atrial flutter (level IIa B EHRA)”.(30)

Figure 3:

  • ECG before ablation:
  • Endocavitary ECG
  • Appearance of AT/F conducted in 3/1 with activation of the proximal to distal CS.
  • The tachycardia cycle is 249 ms

Figure 4:

  • -We had made an activation map in flutter. activation shows a dual circuit around the RSPV.
  • - All the PV where connected.
  • -The mitral isthmus is blocked

Figure 5:

  • -This map view illustrates the double loop around the RSPV with a gap on the roof

    - Very slow and low voltage conduction zone

    -Gap  critical isthmus of the AT

  • After the isolation of the VPs, in particular the RSPV, a shot at the gap area on the roof allowed the return to RS.

Removal of gap areas around the veins:

- Ablation at 40W on the ridge to isolate the VPGs (image 2)

- Ablation at 30W on the two posterior gaps of the VPDs (image 1)

- Then at 35W on the anterior rim (image 3)

Control shows vein insulation and a full two-way block on the roof.


The procedure lasted 115 min (ablation time 80 min, fluoroscopy 15 min).

Third case:

Clinical history:

This is a 65-year-old patient with hypertension and coronary artery disease and BMI 27. He had benefited from 2 ablations for FA in the past.

-The first ablation was to isolate the VPs and fragmented potentials.

-The second ablation consisted of making a roofline, an anterior line and the mitral isthmus which allowed the return to sinus rhythm. symptomatic atrial flutter (level IIa B EHRA)”.(30)

This patient was readmitted for dyspnea and palpitations in connection with a recurrence of flutter conducted in 3/1. the echocardiogram showed undilated LV with 60% LVEF and moderately dilated OG with an area of 23 cm2.

Figure 6:

  • Endocavitary ECG with 323ms cycle and proximal to distal CS activation.

Figure 7:

  • we observed that once the signal is lost in the LA, it reappears in the RA and depolarizes the IAS and then the LA again.
  • In addition, it was observed that the septal  emergence comes from the anterior block line as confirmed by the Lumipoint

So, we made an OD activation card that allowed us to complete the cycle and understand the circuit of this flutter.

We observed that the activation blank once after depolarizing the OG disappears in the DO and reappears on the AIS to depolarize the OG again as shown by the Lumipoint.


The procedure lasted 185min (ablation time 120 min, fluoroscopy 25 min).

Discussion and mechanisms:

What do we know about the treatment of AF:

1 / The control of the rhythm and superior to the frequency control (1,2,3,4).

2 / The AF catheter ablation is superior to medical treatment since A4 and APAF study ( 5,6).

3 / We know that there are risk factors that expose you to more recurrences . These risk factors are age(7,8), hypertension( 7,8,9) Obesity(10), SAS(11),heart disease(6,7,8),size of the atrium(7), alcohol(12).

4/ since we do the ablation of the AF with the lines or ablation of fragmented potentials we ourselves create circuits of flutter or AT (27,28)

5/ We also know that there are internal structural mechanisms that generate and maintain of AF (13,14,15,16,18). There are also genetic factors, external factors such as sport through the autonomic nervous system but also by dilation of the atrium.

A/Rapid ectopic focus.

B/Reentry with conduction fibrillatory.

C/ Reentry wavelets multiple.

D/association of all mechanisms.

We have seen 3 clinical cases in which the arrhythmia recurrence occurred through the roof of the LA.

- The first case was a recurrence in the form of AF with both a partial reconnection of the PV and a gap on the roof. This is the most frequent mechanism that we find during reoperations for ablation.

- In the other 2 clinical cases what is very interesting is the role that the Bachmann beam played to maintain this flutter. This mechanism is rare but described by some authors and will explain the difficulty in restoring a sinus rhythm in this form of arrhythmia.

Anatomy of the auricles in sky blue RA in dark blue LA.

-At the RA level we see the VCS and VCI. The right appendage, the sinus node, the crista terminalis, and the pectineus muscle.

-At the level of the LA we see(26) VPs, the left appendage.

- Between the 2 we see the insertion of the Bachmann vessel, the fossa ovalis and the CS (23)

There are 3 activation modes:

A: Focal and generates an AT.

B: Leak activation mode which rather generates an aspect of flutter.

C: Mode wave activation mode which also generates an aspect of flutter

In the first case, the activation mode was LEAK and generated a roof flutter but with an epicardial passage.

Figure 8: 

  • The mechanism described by Kitamura in circulation and Chengye in the journal of electrocardiography (13,14)
  • RA and LA mapping This activation is linked to the bi-atrial mechanisms
  • Characteristics of a single-loop macroreentrant biatrial AT identified by ultrahigh-resolution mapping system.


There is no consensus on what to do for the ablation of persistent AFA. Rhythmologists try to reproduce the MAZE type ablation performed by surgeons with very complete ablation (VP, roofline, line on the mitral the alcoholization of the Marschall vein and the coronary sinus to reach the epicardium. from this, they remove the cavotricuspid isthmus.

Note: Kindly go through the PDF for the detailed articles with figures



1.Di Biase L Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients with Congestive Heart Failure and an Implanted Device: Results from the AATAC Multicenter Randomized Trial Circulation. 2016 Apr 26;133(17):1637-44.

2.Mohammed N. Khan Pulmonary-Vein Isolation for Atrial Fibrillation in Patients with Heart Failure

PABA-CHF Investigators N Engl J Med 2008;359:1778-85.

3.Nassir F. Marrouche, M.D. Catheter Ablation for Atrial Fibrillation with Heart Failure. CASTEL-AF

N Engl J Med 2018; 378:417-27.

4.Douglas L. Packer. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest. Among Patients with Atrial Fibrillation. The CABANA Randomized Clinical Trial JAMA. 2019;321(13):1261-1274. doi:10.1001/jama.2019.0693.

5.Jaïs P, Catheter ablation versus antiarrhythmic drugs for atrial fibrillation: the A4 study Circulation. 2008 Dec 9;118(24):2498-505.

6.Carlo Pappone. A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: the APAF Study. J Am Coll Cardiol2006 Dec 5 ;48(11):2340-7.

7.Rajeev K. Aggressive Risk Factor Reduction. Study for Atrial Fibrillation and Implications for the Outcome of Ablation The ARREST-AF Cohort Study J Am Coll Cardio 2014; 64:2222–31

8.Wong CX, Brooks AG, Leong DP, et al. The increasing burden of atrial fibrillation compared with heart failure and myocardial infarction: a 15-year study of all hospitalizations in Australia. Arch Intern Med 2012 ;172 :739–41.

9.Conen D, Tedrow UB, Koplan BA, et al. Influence of systolic and diastolic blood pressure on the risk of incident atrial fibrillation in women. Circulation 2009; 119:2146–52.

10.Wang TJ, Parise H, Levy D, et al. Obesity and the risk of new-onset atrial fibrillation. JAMA 2004; 292:2471–7.

11.Gami AS, Hodge DO, Herges RM, et al. Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation. J Am Coll Cardiol 2007; 49:565–71.

12.Kodama S, Saito K, Tanaka S, et al. Alcohol consumption and risk of atrial fibrillation: a meta- analysis. J Am Coll Cardiol 2011 ;57 :427–36.

13.Chegye Di, MD, PHD and All. A single loop macroreentrant biatrial flutter identified by the Rythmia mapping system. Journal of electrocardiology 60 (2020) 107-109.

14.Kitamurat and all. Characteristics of single-loop macroreentrant biatrial tachycardia diagnosed by ultrahigh-resolution mapping system. Circul Arrhythm Elecrtophysiol 2018;11 (2): e 005558.

15.Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, and all. HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendation. Europace. 2007 ;9:335–79.

16.Allessie MA, Lammers WJEP, Bonke FIM, Hollen J. Experimental evaluation of Moe’s multiple wavelet hypothesis of atrial fibrillation. In : Zipes DP, Jalife J, eds. Cariac Arrhythmi- as. New York: Grune & Stratton 1985:265–76.

17.Jalife J, Berenfeld O, Mansour M. Mother rotors and fibrilla- tory conduction: a mechanism of atrial fibrillation. Cardiovasc Res. 2002; 54:204–16.

18.HaissaguerreM, MarcusFI, FischerB, ClementyJ. Radiofrequency catheter ablation in unusual mechanisms of atrial fibrillation: report of three cases. J Cardiovasc Electrophysiology. 1994; 5:743–51.

19.Nattel S, Shiroshita-Takeshita A, Brundel BJ, Rivard L. Mechanisms of atrial fibrillation: lessons fr animal models. Prog Cardiovascular Dis. 2005; 48:9–28.

20.E. Tessitore* V. N. Tran* H. Sunthorn H. Burri M. Namdar D. Shah Suivi a? très long terme après ablation par radiofréquence de la fibrillation auriculaire : expérience a? Genève Revu Med Suisse 2015 ; 11

21.HaissaguerreM, JaisP, ShahDC,TakahashiA,HociniM,Quiniou G, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. New Engl J Med. 1998;339:659–6: 1180-4

22.Amir Ali Fassa Mécanismes physiopathologiques de la fibrillation auriculaire The Journal of cardiovascular medicine · September 2008

23.Antoine Gérard Modèles numériques personnalisés de la fibrillation auriculaire UNIVERSITEi DE BORDEAUX EiCOLE DOCTORALE DE MATHEiMATIQUES ET D’INFORMATIQUE 2019.

24.Thomas Pambrun, MD Epicardial course of the septopulmonary bundle: Anatomical considerations and clinical implications for roof line completion Heart Rhythm, Vol -, No -, - 2020

25.Garcia F, Enriquez F, Arroyo A, Supple G, Marchlinski F, Saenz L. Roof-dependent atrial flutter with an epicardial component: role of the septopulmonary bundle. J Cardiovasc Electrophysiology 2019; 30:1159–1163.

26.Wang K, Ho SY, Gibson DG, Anderson RH. Architecture of atrial musculature in humans. Br Heart J 1995; 73:559–565.

27.Hocini M, Jaïs P, Sanders P, et al. Techniques, evaluation, and consequences of linear block at the left atrial roof in paroxysmal atrial fibrillation: a prospective randomized study. Circulation 2005; 112:3688– 3696.

28.Wolf M, Haddad ME, Fedida J, et al. Evaluation of left atrial linear ablation using contiguous and optimized radiofrequency lesions: the ALINE study. Europace 2018 ;20 :401–409.

29.Piorkowski C, Kronborg M, Hourdain J, et al. Endo-/epicardial catheter ablation of atrial fibrillation: feasibility, outcome, insights into arrhythmia mechanisms. Circ Arrhythm Electrophysiol 2018;11:e005748.

30.CC Cheung · 2021 · — Management of Atrial Fibrillation in 2021: An Updated Comparison of the Current CCS/CHRS, ESC, and AHA/ACC/HRS Guidelines.

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