Electroanatomic Characterization and Ablation of Scar-Related Isthmus Sites Supporting Perimitral Flutter

Katritsis, George; Luther, Vishal; Cortez‐Dias, Nuno; Carpinteiro, L; Sousa, João de; Lim, Phang Boon; Whinnett, Zachary I.; Ng, Fu Siong; Koa‐Wing, Michael; Qureshi, Norman; Chow, Anthony; Agarwal, Sharad; Jamil‐Copley, Shahnaz; Peters, Nicholas S.; Linton, Nick; Kanagaratnam, Prapa

doi:10.1016/j.jacep.2020.10.017

Cited by 9 publications

(12 citation statements)

References 20 publications

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“…Empirical linear ablation for macroreentry atrial tachycardias has been frequently reported in patients with and without CHD 6,10–12,15 . Tachycardias ablated with linear RF strategies have higher long‐term arrhythmia recurrence rates of 30%–49% especially in complex anatomical substrates, often with the reappearance of the same ablated tachycardia 12,16–18 . Recently, recurrence rates of 70% were documented at redo procedure due to recovery of ablation lines 12,18 .…”

Section: Discussionmentioning

confidence: 99%

“…6,[10][11][12]15 Tachycardias ablated with linear RF strategies have higher long-term arrhythmia recurrence rates of 30%-49% especially in complex anatomical substrates, often with the reappearance of the same ablated tachycardia. 12,[16][17][18] Recently, recurrence rates of 70% were documented at redo procedure due to recovery of ablation lines. 12,18 In a multicenter European registry non-HD mapping catheters were used in the vast majority of cases.…”

Section: Follow-upmentioning

confidence: 99%

“…12,18 In a multicenter European registry non-HD mapping catheters were used in the vast majority of cases. 18 Ablation lesions with a mean length of >30 mm were correlated with higher reoccurence rates 12,17 and anatomical guided linear ablation had significantly less favorable clinical outcomes compared to scar-related ablation. 17 Katritsis et al 17 compared empirical linear ablation with critical isthmus ablation in perimitral atrial flutter in a multicentre study.…”

Section: Follow-upmentioning

confidence: 99%

“…18 Ablation lesions with a mean length of >30 mm were correlated with higher reoccurence rates 12,17 and anatomical guided linear ablation had significantly less favorable clinical outcomes compared to scar-related ablation. 17 Katritsis et al 17 compared empirical linear ablation with critical isthmus ablation in perimitral atrial flutter in a multicentre study. Ablation at the critical isthmus maintaining tachycardia and avoidance of anatomical linear lesions had a higher tachycardia termination rate and less requirement of RF energy application, which were findings compatible with our study.…”

Section: Follow-upmentioning

confidence: 99%

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Targeted cluster ablation of non‐CTI‐dependent atrial arrhythmias in congenital heart disease using ultrahigh‐definition mapping

Kefala

Claridge

Wijayagoonawardana

et al. 2022

Cardiovasc electrophysiol

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Background: Ablation of atrial arrhythmias in patients with congenital heart disease (CHD) has markedly improved with advanced mapping systems. However, recurrence rates remain high. The linear ablation strategy is not uncommonly practiced necessitating prolonged ablation times. We report the outcomes of adopting a strategy of minimal, cluster delivery of radiofrequency (RF) energy at critical substrates identified by ultrahigh-definition mapping for atrial arrhythmias in patients with CHD.Methods: Non-cavotricuspid isthmus (non-CTI) atrial tachycardias were ablated with a targeted ablation cluster technique (TACT) using an ultrahigh-density mapping system combined with multielectrode monitoring and endpoint determination in preference to linear ablation. The arrhythmia substrates, RF times, and acute-and medium-term success rates were studied.Results: Fifty-eight tachycardias were mapped and ablated in 42 procedures: 34 non-CTIs and 24 CTIs. A targeted ablation cluster was performed for non-CTI tachycardias, with a median ablation time of 3.1 min. In 53% of non-CTI tachycardias, arrhythmia termination was achieved with ≤2 RF applications. After a mean followup of 23.6 months, 27 (80%) patients were free of recurrent atrial arrhythmias. One of 34 targeted non-CTI tachycardia recurred, with a final success rate of 91%. Linear ablation was performed for CTI flutters with a median ablation time of 6.8 min (vs. non-CTIs, p = .006). Three of 21 tachycardias recurred due to reconnection of the ablation line but the final success rate was 100%. Conclusions:The TACT approach for non-CTI atrial arrhythmias in congenital patients as guided by the ultrahigh-density mapping is an effective method with short ablation times and excellent medium-term outcomes.

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Section: Discussionmentioning

confidence: 99%

Section: Follow-upmentioning

confidence: 99%

Section: Follow-upmentioning

confidence: 99%

Section: Follow-upmentioning

confidence: 99%

See 2 more Smart Citations

Targeted cluster ablation of non‐CTI‐dependent atrial arrhythmias in congenital heart disease using ultrahigh‐definition mapping

Kefala

Claridge

Wijayagoonawardana

et al. 2022

Cardiovasc electrophysiol

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“…In another study, ablation of scar-related critical isthmus maintaining PMAT was found to be highly effective. 22 However, the report said that the most common site for the critical isthmus was the anterior wall of the LA. In Epi-PMAT in which endocardial LMI conduction has been already blocked, the creation of conduction block in the anterior wall of the LA leads to a risk of additional conduction disturbance of the left atrial appendage.…”

Section: Electrophysiological Characteristics Of Pmats and Outcome Of Ablationmentioning

confidence: 99%

Perimitral atrial tachycardias dependent on residual nonligament of Marshall conduction

Sato

Kusa

Yamao

et al. 2021

Cardiovasc electrophysiol

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Introduction: Catheter ablation for perimitral atrial tachycardia (PMAT) that persists despite lateral mitral isthmus (LMI) ablation is challenging. The aim of this study was to identify the role of the ligament of Marshall (LOM) in PMATs that persist after LMI conduction block has been created, and evaluate the validity of ethanol infusion into the vein of Marshall (VOM) as treatment.Methods and Results: Sixteen consecutive PMATs in 13 patients that persisted despite apparent LMI conduction block, which was confirmed by ultrahighresolution mapping and entrainment pacing along the mitral annulus, were analyzed.PMATs were classified into two types based on the location of the endocardial breakthrough site: those utilizing the LOM (n = 13), which had a breakthrough site along with the LOM, and those not utilizing the LOM (n = 3), which had a breakthrough site at an anterior or posterior side of the LOM. Of the 16 PMATs, 5 PMATs (31%) were not suitable for ethanol infusion into the VOM because the LOM was not involved in the tachycardia circuit or because of the anatomy of the VOM.Fourteen PMATs (88%) were successfully terminated solely by breakthrough site ablation. At a mean follow-up period of 12 ± 9 months, 10 (77%) patients have remained free from atrial tachyarrhythmias. Conclusion:In cases of PMAT following LMI ablation, epicardial conduction over the LMI can occur independently of the LOM. Ethanol infusion into the VOM in such cases would not abolish residual epicardial conduction. The anatomy of the VOM can also preclude the use of this method.

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Ripple AT Plus — isthmus-guided vs conventional ablation in the treatment of scar-related atrial tachycardia: study protocol for a randomised controlled trial

Kailey,

Kemp,

Taylor

et al. 2023

J Interv Card Electrophysiol

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Background Catheter ablation is routinely used to treat scar-related atrial tachycardia (s-AT). Conventional ablation often involves creating anatomical “lines” that transect myocardial tissue supporting reentry. This can be extensive, creating iatrogenic scar as a nidus for future reentry, and may account for arrhythmia recurrence. High-density mapping may identify “narrower isthmuses” requiring less ablation, with ripple mapping proven to be an effective approach in identifying. This trial explores whether ablation of narrower isthmuses in s-AT, defined using ripple mapping, results in greater freedom from arrhythmia recurrence compared to conventional ablation. Methods The Ripple-AT-Plus trial (registration ClinicalTrials.gov, NCT03915691) is a prospective, multicentre, single-blinded, randomised controlled trial with 12-month follow-up. Two hundred s-AT patients will be randomised in a 1:1 fashion to either “ripple mapping-guided isthmus ablation” vs conventional ablation on the CARTO3 ConfiDENSE system (Biosense Webster). The primary outcome will compare recurrence of any atrial arrhythmia. Multicentre data will be analysed over a secure web-based cloud-storage and analysis software (CARTONETTM). Conclusion This is the first trial that considers long-term patient outcomes post s-AT ablation, and whether targeting narrower isthmuses in the era of high density is optimal.

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Electroanatomic Characterization and Ablation of Scar-Related Isthmus Sites Supporting Perimitral Flutter

Cited by 9 publications

References 20 publications

Targeted cluster ablation of non‐CTI‐dependent atrial arrhythmias in congenital heart disease using ultrahigh‐definition mapping

Targeted cluster ablation of non‐CTI‐dependent atrial arrhythmias in congenital heart disease using ultrahigh‐definition mapping

Perimitral atrial tachycardias dependent on residual nonligament of Marshall conduction

Ripple AT Plus — isthmus-guided vs conventional ablation in the treatment of scar-related atrial tachycardia: study protocol for a randomised controlled trial

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