Electroanatomic characterization and ablation of scar-related isthmus sites supporting perimitral flutter
File(s)j.jacep.2020.10.017.pdf (3.97 MB) Ripple perimitral manuscript JACC EP.docx (85.39 KB)
Published version
Accepted version
Author(s)
Type
Journal Article
Abstract
Objectives The authors reviewed 3-dimensional electroanatomic maps of perimitral flutter to identify scar-related isthmuses and determine their effectiveness as ablation sites. Background Perimitral flutter is usually treated by linear ablation between the left lower pulmonary vein and mitral annulus. Conduction block can be difficult to achieve, and recurrences are common. Methods Patients undergoing atrial tachycardia ablation using CARTO3 (Biosense Webster Inc., Irvine, California) were screened from 4 centers. Patients with confirmed perimitral flutter were reviewed for the presence of scar-related isthmuses by using CARTO3 with the ConfiDense and Ripple Mapping modules. Results Confirmed perimitral flutter was identified in 28 patients (age 65.2 ± 8.1 years), of whom 26 patients had prior atrial fibrillation ablation. Scar-related isthmus ablation was performed in 12 of 28 patients. Perimitral flutter was terminated in all following correct identification of a scar-related isthmus using ripple mapping. The mean scar voltage threshold was 0.11 ± 0.05 mV. The mean width of scar-related isthmuses was 8.9 ± 3.5 mm with a conduction speed of 31.8 ± 5.5 cm/s compared to that of normal left atrium of 71.2 ± 21.5 cm/s (p < 0.0001). Empirical, anatomic ablation was performed in 16 of 28, with termination in 10 of 16 (63%; p = 0.027). Significantly less ablation was required for critical isthmus ablation compared to empirical linear lesions (11.4 ± 5.3 min vs. 26.2 ± 17.1 min; p = 0.0004). All 16 cases of anatomic ablation were reviewed with ripple mapping, and 63% had scar-related isthmus. Conclusions Perimitral flutter is usually easy to diagnose but can be difficult to ablate. Ripple mapping is highly effective at locating the critical isthmus maintaining the tachycardia and avoiding anatomic ablation lines. This approach has a higher termination rate with less radiofrequency ablation required.
Date Issued
2021-05-01
Date Acceptance
2020-10-24
ISSN
2405-5018
Publisher
Elsevier
Start Page
578
End Page
590
Journal / Book Title
JACC: Clinical Electrophysiology
Volume
7
Issue
5
Copyright Statement
© 2021 by the American College of Cardiology Foundation. Published by Elsevier. This manuscript is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International Licence http://creativecommons.org/licenses/by-nc-nd/4.0/
Sponsor
British Heart Foundation
British Heart Foundation
Identifier
https://www.sciencedirect.com/science/article/pii/S2405500X20311853?via%3Dihub
http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000654047400003&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=1ba7043ffcc86c417c072aa74d649202
Grant Number
RG/16/3/32175
FS/15/12/31239
Subjects
Science & Technology
Life Sciences & Biomedicine
Cardiac & Cardiovascular Systems
Cardiovascular System & Cardiology
atrial tachycardia
catheter ablation
electroanatomic mapping
isthmus
outcomes
perimitral flutter
ATRIAL TACHYCARDIA
MACROREENTRANT TACHYCARDIA
FIBRILLATION
atrial tachycardia
catheter ablation
electroanatomic mapping
isthmus
outcomes
perimitral flutter
Aged
Atrial Fibrillation
Atrial Flutter
Catheter Ablation
Cicatrix
Heart Atria
Humans
Heart Atria
Cicatrix
Humans
Atrial Fibrillation
Atrial Flutter
Catheter Ablation
Aged
Science & Technology
Life Sciences & Biomedicine
Cardiac & Cardiovascular Systems
Cardiovascular System & Cardiology
atrial tachycardia
catheter ablation
electroanatomic mapping
isthmus
outcomes
perimitral flutter
ATRIAL TACHYCARDIA
MACROREENTRANT TACHYCARDIA
FIBRILLATION
Publication Status
Published
Date Publish Online
2021-01-27