Atrial tachycardia originating from the cavo-tricuspid isthmus may exhibit narrow P waves

An 83-year-old man underwent electrophysiological testing for focal atrial tachycardia (AT) exhibiting narrow P waves with negative deflections in the inferior leads. Catheter ablation at the cavo-tricuspid isthmus (CTI) successfully eliminated the AT. The propagation map during AT and pacing study from the successful ablation site demonstrated that the atrial activation throughout the CTI did not produce significant P wave deflections. Consequently, during AT, the left atrial activation time determined the P wave duration. This case demonstrates that AT originating from the CTI may exhibit narrow P waves which can be misinterpreted as AT originating from the inter-atrial septum.