A 57-year-old man with repetitive long R–P supraventricular tachycardia (SVT) was referred for radiofrequency catheter ablation. SVT was sensitive to adenosine triphosphate, was not linked between atrial and ventricular activation, and did not terminate with the ventricular response; thus, we speculated reentrant atrial tachycardia (AT). Although the mitral annulus (MA) was the earliest atrial activation site (EAAS; 5 o’clock), AT was ablated not at the EAAS, but at the tricuspid annulus (TA; 4 o’clock), 24 ms later than the EAAS. We suggest that preferential conduction from the TA to the EAAS of the MA may be involved in AT.

Although a high-resolution three-dimensional mapping system has made it possible to treat complicated atrial tachyarrhythmia (AT), there remain cases that are difficult to diagnose and treat. 1,2 When a single atrial tachycardia is present and stable, mapping is relatively easy. However, when multiple different ATs alternately appear, mapping and diagnosis of those are more difficult. Parallel mapping module is well known as a good option to simultaneously map two or more different ATs when they alternately appear. 3 When performing parallel mapping of two different ATs, one bipolar signal of the reference catheter is used as a timing reference and a cycle length filter is used for differentiating AT1, AT2, and others, including sinus rhythm, fusion beats, or catheter-induced premature atrial complex. Therefore, it has some limitations for differentiating multifocal ATs. We present a case wherein multifocal ATs were successfully eliminated by combining parallel mapping module and dual-chamber intra-cardiac pattern matching technique that we have previously reported. 4

Biatrial tachycardia (BiAT) is a rare arrhythmia, and identification of the re-entry circuit is often complicated. 1 By creating an activation map of the right atrium, left atrium, and coronary sinus as a single chamber, the Lumipoint module of the Rhythmia mapping system can be used in real time to make an accurate diagnosis. 2 Ablation of the Bachmann bundle is a feasible way to terminate BiAT, but might cause interatrial conduction delay and electrical isolation of the left atrial appendage. Chemical ablation into the vein of Marshall might be the more beneficial treatment, avoiding any potential interatrial conduction delay.