Author + information
- Received November 13, 2017
- Revision received March 1, 2018
- Accepted March 6, 2018
- Published online May 2, 2018.
- Heiko Lehrmann, MDa,∗ (, )
- Amir S Jadidi, MDa,
- Jan Minners, MD, PhDa,
- Juan Chen, MDa,
- Björn Müller-Edenborn, MDa,
- Reinhold Weber, MDa,
- Olaf Dössel, PhDb,
- Thomas Arentz, MDa and
- Axel Loewe, PhDb
- aDepartment of Cardiology and Angiology II, University Heart Center Freiburg/Bad Krozingen, Bad Krozingen, Germany
- bInstitute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
- ↵∗Address for correspondence:
Dr. Heiko Lehrmann, Department of Cardiology and Angiology II, University Heart Center Freiburg/Bad Krozingen, Suedring 15, 79189 Bad Krozingen, Germany.
Objectives This study hypothesized that P-wave morphology and timing under left atrial appendage (LAA) pacing change characteristically immediately upon anterior mitral line (AML) block.
Background Perimitral flutter commonly occurs following ablation of atrial fibrillation and can be cured by an AML. However, confirmation of bidirectional block can be challenging, especially in severely fibrotic atria.
Methods The study analyzed 129 consecutive patients (66 ± 8 years, 64% men) who developed perimitral flutter after atrial fibrillation ablation. We designed electrocardiography criteria in a retrospective cohort (n = 76) and analyzed them in a validation cohort (n = 53).
Results Bidirectional AML block was achieved in 110 (85%) patients. For ablation performed during LAA pacing without flutter (n = 52), we found a characteristic immediate V1 jump (increase in LAA stimulus to P-wave peak interval in lead V1) as a real-time marker of AML block (V1 jump ≥30 ms: sensitivity 95%, specificity 100%, positive predictive value 100%, negative predictive value 88%). As V1 jump is not applicable when block coincides with termination of flutter, absolute V1 delay was used as a criterion applicable in all cases (n = 129) with a delay of 203 ms indicating successful block (sensitivity 92%, specificity 84%, positive predictive value 90%, negative predictive value 87%). Furthermore, an initial negative P-wave portion in the inferior leads was observed, which was attenuated in case of additional cavotricuspid isthmus ablation. Computational P-wave simulations provide mechanistic confirmation of these findings for diverse ablation scenarios (pulmonary vein isolation ± AML ± roof line ± cavotricuspid isthmus ablation).
Conclusions V1 jump and V1 delay are novel real-time electrocardiography criteria allowing fast and straightforward assessment of AML block during ablation for perimitral flutter.
This study received financial support from the “Deutsche Forschungsgemeinschaft (DFG)” through CRC 1173. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All 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 November 13, 2017.
- Revision received March 1, 2018.
- Accepted March 6, 2018.
- 2018 The Authors