Pouched Mitral Isthmus Is Associated with Incomplete Linear Block in Atrial Fibrillation Patients with Mechanical Mitral Valve Replacement

Deng, Wen-Ning; Chen, Ke; Bai, Rong; Zhang, Zhijun; Li, Songnan; Wen, Zhaoying; Zhang, Chen; Yu, Rong‐Hui; Tang, Ri‐Bo; Sang, Caihua; Liu, Nian; Guo, Xueyuan; Wu, Xiaoyan; Nie, Jungang; Du, Xin; Ma, Changsheng

doi:10.1111/jce.12649

Cited by 4 publications

(3 citation statements)

References 23 publications

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“…Possible reasons: (1) The pouch structure existed in the isthmus of the mitral valve after valve replacement, which was the main reason affecting the MI linear block. Long et al and Deng et al 20,21 both reported that the isthmus of the mitral valve in patients with mechanical MVR may have pouched MI, which might result in significantly increasing the difficulty in the achievement of block across MI line. (2) Statistical Class II errors might be caused by the small sample size of this study.…”

Section: Discussionmentioning

confidence: 99%

Safety and effectiveness of catheter ablation of atrial fibrillation in patients with mitral valve replacement mechanical versus bioprosthetic valves

Liu,

Long,

Dong

et al. 2023

Preprint

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Introduction: The safety and effectiveness of catheter ablation in patients with atrial fibrillation (AF) who underwent mechanical mitral valve replacement (MVR) have been reported. However, the impacts of different types of mitral valves on the safety and effectiveness of catheter ablation in patients with AF who underwent MVR have not been elucidated. Methods and results: From 2015 to 2021, 17,496 patients underwent catheter ablation of AF for the first time in Beijing Anzhen Hospital were screened. The inclusion criteria were (1) aged 18 years or older; (2) diagnosed with AF; (3) history of mitral valve replacement. The exclusion criteria were a history of catheter ablation, surgical maze procedure, left atrial appendage closure or resection. A total of 68 patients were enrolled in the study. The patients were divided into two groups: the bioprosthetic MVR group (n=12) and the mechanical MVR group(n=58). The size of the left atrial was larger (49.5mm vs. 46.0mm, p<0.05), the thickness of the left interventricular septum was larger (11.0mm vs. 10.0mm, p<0.05), and the mitral ring area was smaller (2.3mm2 vs. 2.6mm2, p<0.05) for the bioprosthetic MVR group than the mechanical MVR group. During 23.4 (6.1, 36.5) months of follow-up, the incidence of the endpoint events was not significantly different between the two groups (33.3% vs. 30.4%, log-rank p=0.48). There were 2 cases (3.4%) of pseudoaneurysm and 1 case of acute cerebral infarction in the mechanical MVR group. No complication was observed in the bioprosthetic MVR group. No significant clinical bleeding events were observed in the bioprosthetic group while eight patients in the mechanical MVR groups had bleeding events (p=0.368) during the follow-up. Conclusion: The safety and effectiveness of catheter ablation of AF were comparable between the patients with mechanical MVR and bioprosthetic MVR.

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Section: Discussionmentioning

confidence: 99%

Safety and effectiveness of catheter ablation of atrial fibrillation in patients with mitral valve replacement mechanical versus bioprosthetic valves

Liu,

Long,

Dong

et al. 2023

Preprint

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“…Therefore, the ideal site of balloon occlusion should be as proximal as possible to the juncture of VOM with CS, in order to achieve a larger intervention area, covering the connections between CS and LA (example.g., CS‐LAA connections). However, even with EIVOM, some patients with complex MI anatomy, such as those with mechanical mitral valve, 24 inherit pouch at the isthmus, the interposition of the circumflex artery in the vicinity of MI and the CS, or with a history of hypertrophic cardiomyopathy, are inevitably associated with a lower probability of achieving complete MI block.…”

Section: Discussionmentioning

confidence: 99%

Vein of Marshall ethanol infusion: First‐step or adjunctive choice for perimitral atrial tachycardia?

Gao

Sang

Huang

et al. 2022

Pacing Clinical Electrophis

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Background: Perimitral atrial tachycardia (PMAT) is the most frequent type of iatrogenic atrial tachycardia (AT) after atrial fibrillation (AF) ablation. Vein of Marshall ethanol infusion (EIVOM) is a promising technique in mitral isthmus (MI) ablation.Methods: A total of 165 patients with PMAT were divided into three groups according to ablation strategies, including RF only group (n = 89), RF-EIVOM group (initial RF ablation with adjunctive EIVOM, n = 28), and EIVOM-RF group (first-step EIVOM with touch-up RF ablation, n = 48). Acute and follow-up procedure outcomes were evaluated.Results: PMAT terminated in 89.9%, 89.3%, and 93.7% of patients in RF only, RF-EIVOM and EIVOM-RF groups, respectively (p = .715), with complete MI block achieved in 80.9%, 89.3%, and 95.8% of patients (EIVOM-RF vs. RF only, p = .012).First-step utilization of EIVOM was associated with a significant shortening of RF ablation time at MI (EIVOM-RF 2.1 ± 1.3 min, RF only 7.9 ± 5.9 min, RF-EIVOM 6.8 ± 5.8 min; p < .001) and a decrease in the proportion of patients need ablation within coronary sinus (CS, EIVOM-RF 14.6%, RF only 61.8%, RF-EIVOM 64.3%; p < .001). After a mean follow-up of 12.1 ± 6.2 months, AF/AT recurred in 39 (43.8%), 6 (21.4%), and 12 (25.0%) patients in RF only, RF-EIVOM, and EIVOM-RF group (RF-EIVOM vs. RF only, p = .026; EIVOM-RF vs. RF only, p = .022).Conclusions: EIVOM was associated with an enhanced acute MI block rate as well as reduced AF/AT recurrence. First-step utilization of EIVOM promises to significantly simplify the RF ablation process.

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“…As factors associated with a successful MI ablation, previous studies suggested the importance of the steerable sheath and contact force [ 17 ]. Anatomical factors such as the myocardial thickness and presence of pouches, length of the MI and distance to the LCX, high take off of the LIPV, and connection of the VOM have also been reported [ 25 – 28 ]. In this study, an interposition of the LCX was observed significantly more often in the group with an incomplete line of block.…”

Section: Discussionmentioning

confidence: 99%

Mitral isthmus ablation using a circular mapping catheter positioned in the left atrial appendage as a reference for conduction block

et al. 2017

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BackgroundFor perimitral atrial flutter (PMFL) developing after catheter ablation of atrial fibrillation (AF), to create a complete conduction block at the mitral isthmus (MI) is mandatory to terminate it, however, it is still challenging.MethodsThis study consisted of 80 patients (74 male, 61 ± 8.1 years) undergoing MI ablation. After a circular mapping catheter was positioned at the neck of the left atrial appendage (LAA), the MI ablation was performed on the MI line just below the LAA neck targeting the earliest activation recording site of the LAA catheter during pacing from the coronary sinus (CS). When ablation during CS pacing was not successful, an RF delivery during LAA pacing was applied targeting the earliest activation site just below the MI line. If the endocardial approach failed, an RF application inside the CS was attempted.ResultsWith the endocardial approach, acute success was achieved in 51/80 patients (64%). Additional epicardial ablation from the CS was performed in 26/29 (90%) endocardially unsuccessful patients and conduction block at the MI was achieved in 21/26 (81%). Overall, complete conduction block at the MI was achieved in 72/80 patients (90%). At a mean follow-up of 16 ± 6 months, 20 patients (25%) had recurrence of atrial arrhythmias (AT: 12, AF: 8), and 10 (AT: 7, AF : 3) underwent a second procedure in which an LMI block line was completed in 3 (33%). PMFL was diagnosed in 6 out of 7 AT patients. No complications were observed.ConclusionsCreating linear lesions just beneath the neck of the LAA was highly successful under the guidance of a circular mapping catheter in the LAA using a steerable sheath. An RF application from the CS was needed in less than half of the cases.

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Pouched Mitral Isthmus Is Associated with Incomplete Linear Block in Atrial Fibrillation Patients with Mechanical Mitral Valve Replacement

Abstract: Pouched MI accounts for the majority of AF patients with MMVR and may be associated with incomplete bidirectional linear block of MI.

Cited by 4 publications

References 23 publications

Safety and effectiveness of catheter ablation of atrial fibrillation in patients with mitral valve replacement mechanical versus bioprosthetic valves

Safety and effectiveness of catheter ablation of atrial fibrillation in patients with mitral valve replacement mechanical versus bioprosthetic valves

Vein of Marshall ethanol infusion: First‐step or adjunctive choice for perimitral atrial tachycardia?

Mitral isthmus ablation using a circular mapping catheter positioned in the left atrial appendage as a reference for conduction block

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