Focal atrial tachycardia from the ostium of the coronary sinus: electrocardiographic and electrophysiological characterization and radiofrequency ablation.

OBJECTIVES The goal of this study was to characterize the electrocardiographic and electrophysiologic features and frequency of focal atrial tachycardia (AT) originating from the coronary sinus ostium (CS). BACKGROUND The ostium of the coronary sinus has been described as a site of origin of AT, but detailed characterization of these tachycardias is limited. METHODS Thirteen patients (6.7%) of 193 undergoing radiofrequency ablation (RFA) for focal AT are reported. Endocardial activation maps (EAM) were recorded from catheters at the CS (10 pole), crista terminalis (20 pole), and His positions. The P waves were classified negative, positive, isoelectric, or biphasic. RESULTS The mean age was 41 +/- 6 years, seven female patients, with symptoms for 8 +/- 3 years. Tachycardia was induced by programmed extra-stimuli in eight patients, was spontaneous in three patients, and in response to isoproterenol in two patients. These foci had a characteristic P-wave morphology. At the CS ostium, the P-wave was deeply negative in all inferior leads, negative or isoelectric becoming positive in lead V(1), then progressively negative across the precordium. Lead aVL was positive in all patients. Earliest EAM activity occurred at the proximal CS at 20 +/- 3 ms ahead of P-wave. Mean activation time at the successful RFA site = -36 +/- 8 ms; RFA was acutely successful in 11 of 13 patients. Long-term success was achieved in 11 of 11 over a median follow-up of 25 +/- 4 months. CONCLUSIONS The CS ostium is an uncommon site of origin for focal AT (6.7%). It can be suspected as a potential anatomic site of AT origin from the characteristic P-wave and activation timing. Long-term success was achieved with focal ablation in the majority of patients.