2 In addition, the pouch can generate difficulty in maintaining sufficient catheter–tissue contact while withdrawing the catheter from the tricuspid annulus to the inferior vena cava (IVC) if one assumes a planar CTI. A deep sub-Eustachian pouch may cause difficulty with CTI ablation because of poor blood flow, resulting in rapid temperature and impedance rise, possible coagulum formation, and inadequate lesion formation, while concomitantly increasing the risk of perforation. In some individuals this pouch can be prominent, particularly near the septum. The sub-Eustachian pouch (pouch of Keith) is a physiologic depression of the CTI just anterior to the Eustachian ridge and laterally to the Thebesian valve at the orifice of the coronary sinus. ![]() The tachycardia terminated with ablation, but achievement of bidirectional block across the CTI ablation line was challenging. We used a power-controlled setting with a maximum temperature setting of 40☌ and a flow rate of 17 mL/min. Using an open-irrigated 3.5-mm-tip RF ablation catheter (THERMOCOOL, Biosense Webster) through a Swartz Braided SL1 guiding introducer sheath (St Jude Medical, Saint Paul, MN), ablation along the CTI was performed at a power of 30 W with titration guided by impedance and temperature monitoring. Entrainment maneuvers confirmed the atrial flutter to be CTI-dependent. The right atrial electrograms demonstrated high-to-low activation, and the coronary sinus electrograms demonstrated proximal-to-distal activation. An intracardiac echocardiography catheter (ICE ACUNAV, Siemens, Mountain View, CA) was inserted through the right femoral vein ( Figure 2). ![]() Diagnostic catheters were positioned in the high right atrium, annular right atrium across the CTI, coronary sinus, and right ventricle. The patient was brought to the electrophysiology laboratory in atrial flutter. Patient’s electrocardiogram revealing typical atrial flutter.Ī repeat electrophysiologic study was performed.
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