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A 68-year-old man with hypertension, dyslipidemia, obstructive sleep apnea, chronic obstructive pulmonary disease, sick sinus syndrome status post dual chamber pacemaker, and a history of 2 pulmonary vein isolation ablations for persistent atrial fibrillation was evaluated in our institution for recurrent atrial flutter.He underwent a complete electrophysiology study. A duodecapolar catheter was used, so that the distal 10 poles were inside the coronary sinus (CS) and the proximal were in the right atrium. The underlying rhythm was atrial flutter with a cycle length of 350 ms and ostial-to-distal activations in the CS. Responses to entrainment were consistent with a left atrial origin. After a trans-septal puncture, a 3-dimensional map of the left atrium was performed using the NavX system (St Jude Medical, St Paul, MN) and a circular duodecapolar catheter, which was consistent with counterclockwise perimitral flutter (PMF). However, the entire cycle length was not present in the mitral annulus (Figure A and B …

Recurrent Perimitral Flutter due to Vein of Marshall Epicardial Connections Bypassing the Mitral Isthmus