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Lim MW, Morton M, Fernando R, Elbracht-Leong S, Better N, Segan L, William J, Crowley R, Morton JB, Sparks PB, Lee G, McLellan AJ, Ling LH, Sugumar H, Prabhu S, Voskoboinik A, Kalman JM, Kistler PM. Impact of Posterior Wall Isolation During AF Ablation on the Incidence of Left Atrial Flutter. JACC Clin Electrophysiol 2024; 10:1620-1630. [PMID: 38752960 DOI: 10.1016/j.jacep.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/22/2024] [Accepted: 04/22/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Linear and complex electrogram ablation (LCEA) beyond pulmonary vein isolation (PVI) is associated with an increase in left atrial macro-re-entrant tachycardias (LAMTs). Posterior wall isolation (PWI) is increasingly performed to improve AF ablation outcomes. However, the impact of PWI on the incidence of LAMT is unknown. OBJECTIVES The purpose of this study was to establish the incidence of LAMT following PVI alone vs PVI + PWI vs PVI + PWI + LCEA. METHODS Consecutive patients undergoing catheter ablation for AF or LAMT post-AF ablation between 2008 and 2022 from 4 electrophysiology centers were reviewed with a minimum follow-up of 12 months. RESULTS In total, 5,619 (4,419 index, 1,100 redo) AF ablation procedures were performed in 4,783 patients (mean age 60.9 ± 10.6 years, 70.7% men). Over a mean follow-up of 6.4 ± 3.8 years, 246 procedures for LAMT were performed in 214 patients at a mean of 2.6 ± 0.6 years post-AF ablation. Perimitral (52.8% of patients), roof-dependent (27.1%), PV gap-related (17.3%), and anterior circuits (8.9%) were most common, with 16.4% demonstrating multiple circuits. The incidence of LAMT was significantly higher following PVI + PWI (6.2%) vs PVI alone (3.0%; P < 0.0001) and following PVI + PWI + LCEA vs PVI + PWI (12.5%; P = 0.019). Conduction gaps in previous ablation lines were responsible for LAMT in 28.4% post-PVI alone, 35.3% post-PVI + PWI (P = 0.386), and 81.8% post-PVI + PWI + LCEA (P < 0.005). CONCLUSIONS The incidence of LAMT following PVI + PWI is higher than with PVI alone but significantly lower than with more extensive atrial substrate modification. Given a low frequency of LAMT following PWI, empiric mitral isthmus ablation is not justified and may be proarrhythmic.
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Affiliation(s)
- Michael W Lim
- The Alfred Hospital, Melbourne, Australia; The Royal Melbourne Hospital, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | | | | | | | - Nathan Better
- The Royal Melbourne Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Louise Segan
- The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Jeremy William
- The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Rose Crowley
- The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Joseph B Morton
- The Royal Melbourne Hospital, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia
| | - Paul B Sparks
- The Royal Melbourne Hospital, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia
| | - Geoffrey Lee
- The Royal Melbourne Hospital, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Alex J McLellan
- The Royal Melbourne Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; St Vincent's Health, Melbourne, Victoria, Australia
| | - Liang-Han Ling
- The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia
| | - Hariharan Sugumar
- The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; Monash University, Melbourne, Australia; St Vincent's Health, Melbourne, Victoria, Australia
| | - Sandeep Prabhu
- The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; Western Health, Melbourne, Victoria, Australia
| | - Jonathan M Kalman
- The Royal Melbourne Hospital, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Peter M Kistler
- The Alfred Hospital, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; Monash University, Melbourne, Australia.
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Neira V, Hanson M, Tso M, Khakh P, Burak C, Alam M, Sanhueza E, Bakker D, Pardy J, Redfearn D, Chacko S, Simpson C, Abdollah H, Baranchuk A, Enriquez A. Comparison of anterior mitral line and mitral isthmus line for ablation of mitral annular flutter. J Cardiovasc Electrophysiol 2024; 35:1480-1486. [PMID: 38802972 DOI: 10.1111/jce.16325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 05/06/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Mitral annular flutter (MAF) is the most common left atrial macro-reentrant arrhythmia following catheter ablation of atrial fibrillation (AF). The best ablation approach for this arrhythmia remains unclear. METHODS This single-center, retrospective study sought to compare the acute and long-term outcomes of patients with MAF treated with an anterior mitral line (AML) versus a mitral isthmus line (MIL). Acute ablation success, complication rates, and long-term arrhythmia recurrence were compared between the two groups. RESULTS Between 2015 and 2021, a total of 81 patients underwent ablation of MAF (58 with an AML and 23 with a MIL). Acute procedural success defined as bidirectional block was achieved in 88% of the AML and 91% of the MIL patients respectively (p = 1.0). One year freedom from atrial arrhythmias was 49.5% versus 77.5% and at 4 years was 24% versus 59.6% for AML versus MIL, respectively (hazard ratio [HR]: 0.38, confidence interval [CI]: 0.17-0.82, p = .009). Fewer patients in the MIL group had recurrent atrial flutter when compared to the AML group (HR: 0.32, CI: 0.12-0.83, p = .009). The incidence of recurrent AF, on the other side, was not different between both groups (21.7% vs. 18.9%; p = .76). There were no serious adverse events in either group. CONCLUSION In this retrospective study of patients with MAF, a MIL compared to AML was associated with a long-term reduction in recurrent atrial arrhythmias driven by a reduction in macroreentrant atrial flutters.
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Affiliation(s)
- Victor Neira
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Matthew Hanson
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Melissa Tso
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Parm Khakh
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Cengiz Burak
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Maqsood Alam
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Eduardo Sanhueza
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - David Bakker
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Jacob Pardy
- Abbott Medical, Mississauga, Ontario, Canada
| | - Damian Redfearn
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Sanoj Chacko
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | | | - Hoshiar Abdollah
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Andres Enriquez
- Section of Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Gardziejczyk P, Wlazłowska-Struzik E, Skowrońska M, Baran J. Pulsed-field ablation using pentaspline catheter as a bail-out strategy for perimitral flutter related to the left atrium anterior wall scar. HeartRhythm Case Rep 2023; 9:906-909. [PMID: 38204828 PMCID: PMC10774522 DOI: 10.1016/j.hrcr.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
- Piotr Gardziejczyk
- Division of Clinical Electrophysiology, Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Wlazłowska-Struzik
- Division of Clinical Electrophysiology, Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marta Skowrońska
- Division of Clinical Electrophysiology, Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Jakub Baran
- Division of Clinical Electrophysiology, Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
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