conduction because of transverse activation through that structure.

Alternatively, the circuit can exit at the apex of the triangle of Koch
and come behind the eustachian ridge to break through across the crista
terminalis behind the IVC and then return to the CTI.3
Lower loop reentry often coexists with counterclockwise or clockwise
typical AFL and is usually transient and terminates by itself or converts
spontaneously into AFL or atrial fibrillation (AF).
Intra-Isthmus Reentry
Intra-isthmus reentry is a reentrant circuit usually occurring within
the region bounded by the medial CTI and coronary sinus ostium (CS
os) (see Fig. 13.2). Circuits in the mid and lateral portion of the CTI
can also occur but are less common.4
This arrhythmia can be sustained and usually occurs in patients
who have undergone prior, and often extensive, ablation at the CTI.
Catheter ablation can result in islands of scarred areas and slowly
conducting channels that can potentially provide the substrate for
this arrhythmia. In one report, intra-isthmus reentry accounted for
21% of cases of “recurrent” AFL following prior successful CTI
ablation.
Of note, persistence of bidirectional CTI block following ablation
of typical AFL does not exclude the possibility of intra-isthmus
reentry, since the reentry circuit can exist medial to the line of CTI
block. The reentry circuit can be quite small; fractionated potentials
spanning one- to two-thirds of the TCL are typically recorded
within the CTI.4
The atrial activation sequence around the tricuspid annulus electrograms
can exhibit spontaneous or pacing-induced shifts from a
counterclockwise to clockwise or fusion patterns. In addition,
entrainment
mapping from the lateral CTI demonstrates a postpacing interval
(PPI) longer than the TCL, a finding indicating that the lateral CTI is
not part of the reentrant circuit. On the other hand, pacing from the
region of the medial CTI or CS os demonstrates concealed entrainment
with a PPI equal to the TCL. Linear ablation across the medial CTI,
usually at the site of a very prolonged electrogram, can eliminate the
tachycardia.4
Non-CTI-Dependent Right
 Atrial Macroreentry
Incisional Right Atrial Macroreentry
Incisional or scar-mediated RA macroreentry circuits are the most
common form of non-CTI-dependent RA MRATs. The incision on the
RA free wall is a routine access site for corrective surgery for congenital
or acquired heart disease. The atriotomy scar, suture lines, and
cannulation
sites form fixed obstacles that can potentially promote reentry
by providing multiple protected isthmuses along with natural conduction
barriers (such as valve annuli and caval ostia) and regions of atrial
scarring caused by the underlying heart disease. In its simplest form,
incisional RA MRAT uses a circuit that rotates around the atriotomy
scar, with the lower turning point located between the end of the scar
and the IVC, and the upper turning point located between the upper
end of the scar or the superior vena cava (SVC). Other obstacles can
also be included in the reentry circuit, such as anatomical structures
located in the vicinity of the scar (e.g., SVC or IVC) or functional
obstacles (anisotropic conduction delay or block).3
These patients often exhibit multiple clinical or inducible tachycardias,
particularly typical AFL, indicating the complexity of the atrial
substrate. Importantly, the atriotomy scar in the lateral or posterolateral
RA forms a fixed posterior barrier to conduction in the superoinferior
direction between the venae cavae, and a lateral boundary necessary
for the development of a peritricuspid macroreentry (typical AFL) by
preventing short-circuiting of the tricuspid annulus via the posterior
atrium. This explains why typical AFL is the most common AT in this