Incidence, electrophysiological characteristics, and long-term follow-up of perimitral atrial flutter in patients with previously confirmed mitral isthmus block

Abstract

Introduction: After mitral isthmus (ΜΙ) catheter ablation, perimitral atrial flutter (PMF) circuits can be maintained due to the preservation of residual myocardial connections, even if conventional pacing criteria for complete MI block are apparently met (MI pseudo-block). We aimed to study the incidence, the electrophysiological characteristics, and the long-term outcome of these patients. Methods and Results: Seventy-two consecutive patients (mean age 62.4±10.2, 62.5% male) underwent MI ablation, either as part of an atrial fibrillation (AF) ablation strategy (n=35), or to treat clinical reentrant atrial tachycardia (AT) (n=32), or to treat AT that occurred during ablation for AF (n=5). Ιn all patients the electrophysiological characteristics of PMF circuits were studied by high-density mapping. MI block was successfully achieved in 69/72 patients (95.6%). Five patients developed PMF after confirming MI block. In these patients, high-density mapping during the PMF showed a breakthrough in MI with extremely low impulse conduction velocity (CV). In contrast, in usual PMF circuits that occurred after AF ablation, the lower CV of the reentrant circuit was of significantly higher value (0.07±0.02m/s vs 0.25±0.07m/s, respectively; P<0.001).Patients presented with clinical AT had better prognosis in maintaining sinus rhythm after MI ablation compared with patients presented with AF. Conclusion: PMF with MI pseudo-block may be present after MI ablation and has specific electrophysiological features characterized by remarkably slow CV in the MI. Thus, even after MI block is achieved, a more detailed mapping in the boundaries of the ablation line or reinduction attempts may be needed to exclude residual conduction.

Comparison of the Anterior Septal Line and Mitral Isthmus Line for Perimitral Atrial Flutter Ablation Using Robotic Magnetic Navigation

“…Ablation within the CS increases the risk of CS and circumflex artery injury, cardiac tamponade by steam pop, and thrombosis [6]. Furthermore, PMAFL with MI pseudoblock may be present after MI ablation, and a more detailed mapping in the boundaries of the ablation line or reinduction of arrhythmias may be needed to exclude residual conduction [16].…”

Peri‐mitral flutter with epicardial bypass after surgical maze procedure

“…To the best of our knowledge, this is the first to report a PMT with CS bypass after the surgical maze procedure. After the transcutaneous RF MI ablation, residual myocardial connections in the LA may be present and become the cause of arrhythmia recurrence 3 . Epicardial bypass through the vein of Marshall sometimes causes arrhythmia recurrence after the MI ablation or maze procedure 4,5 .…”

“…After the transcutaneous RF MI ablation, residual myocardial connections in the LA may be present and become the cause of arrhythmia recurrence. 3 Epicardial bypass through the vein of Marshall sometimes causes arrhythmia recurrence after the MI ablation or maze procedure. 4,5 Our case demonstrates that the similar phenomenon across the CS can occur after the surgical maze procedure in which residual myocardial connections in the LA did not exist.…”