Septal Versus Lateral Mitral Isthmus Ablation for Treatment of Mitral Annular Flutter
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Author + information
- Ankit Maheshwari, MD, MS,
- Yasuhiro Shirai, MD,
- Matthew C. Hyman, MD, PhD,
- Jeffrey S. Arkles, MD,
- Pasquale Santangeli, MD, PhD,
- Robert D. Schaller, DO,
- Gregory E. Supple, MD,
- Saman Nazarian, MD, PhD,
- David Lin, MD,
- Sanjay Dixit, MD,
- David J. Callans, MD,
- Francis E. Marchlinski, MD and
- David S. Frankel, MD∗ (david.frankel{at}uphs.upenn.edu)
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- ↵∗Address for correspondence:
Dr. David S. Frankel, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104.
Central Illustration
Abstract
Objectives This study sought to compare efficacy and safety of the septal mitral isthmus line (SMIL) with that of the lateral mitral isthmus line (LMIL) for treatment of mitral annular flutter (MAF).
Background MAF is the most common left atrial macro-re-entrant organized atrial tachycardia (OAT) occurring after catheter ablation of atrial fibrillation. The 2 most common lesion sets for treating MAF include linear ablation from the anteroseptal mitral annulus to the right superior pulmonary vein (SMIL) and from the lateral mitral annulus to left inferior pulmonary vein (LMIL).
Methods The study included all mitral isthmus ablations performed at the Hospital of the University of Pennsylvania in 2016 and 2017. Acute procedural results and long-term arrhythmia-free survival were compared between groups.
Results Of 114 total MILs, conduction block was achieved across 73 (93.6%) SMILs compared with 29 (80.6%) LMILs (p = 0.05). Although the length of the SMIL was longer (48.9 ± 12.8 cm vs. 38.7 ± 12.8 cm; p = 0.001), time required to achieve block was shorter (25.2 ± 15.9 min vs. 36.6 ± 21.3 min; p = 0.03). Coronary sinus ablation was required in 58.3% of LMILs due to inability to achieve conduction block with left atrial ablation alone. In multivariate analysis, only failure to achieve acute MIL block remained significantly associated with subsequent OAT recurrence (hazard ratio: 6.39; 95% confidence interval: 1.37 to 29.9; p = 0.02).
Conclusions The SMIL requires less time to complete and more frequently results in acute MIL block than the LMIL. Additionally, ablation is rarely required outside the left atrium. Failure to achieve acute MIL block is strongly associated with subsequent OAT recurrence.
- catheter ablation
- mitral annular flutter
- mitral annular line
- mitral isthmus–dependent flutter
- mitral isthmus line
Footnotes
This work was supported by the Pennsylvania Steel Company EP Research Fund. Dr. Nazarian has received research grant support from Biosense Webster, Siemens, and ImriCor; has served as a consultant for CardioSolv; and has served as a principal investigator for Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received June 28, 2019.
- Revision received August 20, 2019.
- Accepted August 22, 2019.
- 2019 American College of Cardiology Foundation
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