Mitral isthmus block is associated with favorable outcomes after reablation for long‐standing persistent atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Achieving bidirectional mitral isthmus block during radiofrequency (RF) ablation for persistent atrial fibrillation (AF) is still challenging. The conventional ablation method involves RF applications on the endocardial aspect of the Mitral Isthmus (MI), and for a majority of patients, in the distal coronary sinus (CS). Purpose We have evaluated the acute success of obtaining mitral isthmus block by adding another epicardial component using ethanol infusion in the vein of Marshall (EIVOM) in addition to endocardial MI and epicardial CS ablation. Methods We studied 121 patients (pts.) with a mean age of 65 years (range 40-83) 73% men; 119 with longstanding persistent AF (98%) and 2 with perimitral flutter (2%). The mean duration of AF was 53 months (12-244 months). In the majority of patients, additional endocardial (on the ventricular aspect of the MI) and/or epicardial (distal CS) (RF) ablation was performed in order to achieve MIB. The ablation procedure was performed under general anesthesia (GA) for 81 pts (67%). EIVOM was perform with a mean 6 ml ethanol (range 2-10ml) Results Bidirectional MIB was obtained in 114 pts. (94,2%). The 7 patients without MIB were scheduled for another ablation procedure (4 pts under GA during the first procedure). The average RF delivery time to block was 160 seconds (range 42-480 seconds) for the endocardial MI RF ablation (point-by-point application with a power of 50W and an Ablation Index of 450-500, contact force 10-20g) and 156 seconds (range 55-438) for the epicardial MI RF ablation (applications with a power of 20W). Bidirectional endocardial and epicardial MIB was confirmed by conventional pacing maneuvers performed in sinus rhythm. No major complications were observed. The parameters associated with failure for MIB were AF duration, Left Atrial dilatation >200 ml, MI thickness (epicardial endocardial distance on the CARTO maps >15mm). Conclusion Ethanol infusion in the vein of Marshall is a safe approach and is associated with a higher success rate of obtaining acute bidirectional endocardial and epicardial mitral isthmus block when compared with the conventional method. Abstract Figure. Bloc Mitral Endo; Bloc Mitral Epi;

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Comparison of the anterior and posterior mitral isthmus ablation lines in patients with perimitral annulus flutter or persistent atrial fibrillation

Journal of Interventional Cardiac Electrophysiology ◽

10.1007/s10840-015-0033-1 ◽

2015 ◽

Vol 44 (2) ◽

pp. 119-129 ◽

Cited By ~ 10

Author(s):

Martin Huemer ◽

Alexander Wutzler ◽

Abdul Shokor Parwani ◽

Philipp Attanasio ◽

Hisao Matsuda ◽

...

Keyword(s):

Atrial Fibrillation ◽

Persistent Atrial Fibrillation ◽

Mitral Isthmus

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Fractionated Mapping-Guided Ablation Strategy in Patients with Long-Standing Persistent Atrial Fibrillation: a Case Series

Journal of Cardiac Arrhythmias ◽

10.24207/jca.v33i2.3366 ◽

2020 ◽

Vol 33 (2) ◽

pp. 82-88

Author(s):

Tolga Aksu ◽

Tumer Erdem Guler ◽

Serdar Bozyel ◽

Kivanc Yalin

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Paroxysmal Atrial Fibrillation ◽

Case Series ◽

Persistent Atrial Fibrillation ◽

Posterior Wall ◽

Mitral Isthmus

Although pulmonary vein isolation (PVI) remains the cornerstone of ablation for paroxysmal atrial fibrillation (AF), optimal ablation strategy for long-standing persistent AF (LSPAF) remains unclear. This article presents two patients with LSPAF in whom acute AF termination was achieved during ablation by using fractionated-guided extended PVI, posterior wall isolation, and mitral isthmus.

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Comparison of voltage map-guided left atrial anterior wall ablation versus left lateral mitral isthmus ablation in patients with persistent atrial fibrillation

Heart Rhythm ◽

10.1016/j.hrthm.2010.10.015 ◽

2011 ◽

Vol 8 (2) ◽

pp. 199-206 ◽

Cited By ~ 77

Author(s):

Hui-Nam Pak ◽

Yong Seog Oh ◽

Hong Euy Lim ◽

Young-Hoon Kim ◽

Chun Hwang

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Persistent Atrial Fibrillation ◽

Anterior Wall ◽

Mitral Isthmus

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Abstract 3369: Association Between Bi-directional Mitral Isthmus Block and Atypical Flutter Following Left Atrial Linear Ablation in Patients with Symptomatic Atrial Fibrillation

Circulation ◽

10.1161/circ.116.suppl_16.ii_760-b ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Ramtin Anousheh ◽

Navinder Sawhney ◽

Charles Tate ◽

Michael Panutich ◽

Wayne Whitwam ◽

...

Keyword(s):

Atrial Fibrillation ◽

Coronary Sinus ◽

Left Atrial ◽

Pulmonary Veins ◽

List Type ◽

Additional Line ◽

Linear Ablation ◽

Mitral Isthmus ◽

Isthmus Block ◽

The Right

Background: Incomplete or unidirectional mitral isthmus block (MIB) during left atrial linear ablation (LALA) for atrial fibrillation (AF) may be proarrhythmic, and is the most common target for repeat ablation in patients with atypical atrial flutter (AAFL) after LALA. Objective: To determine if achieving bidirectional MIB during LALA will reduce occurrence post-ablation AAFL and/or recurrence of AF. Methods and Results: Fifty-six consecutive patients (pts), 49 males and 7 females, mean age 59±8 years, who underwent LALA for symptomatic, persistent (61%) or paroxysmal (39%) AF were evaluated. Thirty-four pts had been previously ablated, none had MIB from the first ablation. All pts underwent LALA including two encircling lesions around the right and left pulmonary veins, a line at the roof of the left atrium between the two circles, and a line from the lateral mitral valve annulus (MVA) to the left circle with adjunctive coronary sinus ablation as needed to achieve MIB. Thirty pts had an additional line from the septal MVA to the right circle. Bi-directional MIB was documented by pacing from the left atrial appendage and proximal coronary sinus. Bi-directional MIB was achieved in 38 pts (68%), with ablation in the coronary sinus required in 87.5% of pts. Thirty-seven pts underwent LALA with a standard 8 mm tip (Blazer™ or Navistar™) catheter and 19 pts with saline-irrigated catheters (ThermoCool™, Chili™). Patients were followed for 6±2 months. AAFL occurred in 15 pts (27%), and 17 pts (30%) had recurrence of AF. In pts with AAFL, 8 had documented bi-directional MIB during ablation and 7 did not. The odds of AAFL was 7.6 times higher in pts without MIB compared those with MIB (p=0.02); adjusting for age, gender, diagnosis, type of catheter, coronary sinus ablation and history of previous ablation. This study did not show similar association between recurrence of AF and MIB (p=0.5). Conclusions: Achieving bi-directional MIB will reduce incidence of post-ablation AAFL significantly. Recurrence of AF is not reduced by achieving bi-directional MIB.

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