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Crossing the line in perimitral flutter ablation: a new solution for an old problem
Session:
Comunicações Orais - Sessão 03 - Fibrilhação auricular - Inovações no tratamento ablativo
Speaker:
Joana Brito
Congress:
CPC 2023
Topic:
C. Arrhythmias and Device Therapy
Theme:
04. Arrhythmias, General
Subtheme:
04.4 Arrhythmias, General – Treatment
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Joana Brito; Afonso Nunes Ferreira; Gustavo Lima da Silva; Catarina Almeida Barreiros; Diogo Albuquerque; Fernando Santos Silva; Ilda Viana; Manuel Rocha Abecassis; Ricardo Bernardo; Sofia Fernandes; Sara Neto; Luís Carpinteiro; Nuno Cortez-Dias; Fausto Pinto; João de Sousa
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Introduction: </strong>Left-sided atrial flutter (AFl) often implies perimitral circuits, which can be interrupted with linear lesions connecting electro-anatomical obstacles. Inferior mitral line (IML), from the mitral annulus to the left inferior pulmonary vein (PV) is a common strategy to interrupt perimitral circuits, although difficulties in achieving bidirectional blockage are frequent.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Purpose: </strong>To compare the safety and effectiveness of the IML with a modified anterior line (MAL).</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Methods: </strong>Cohort of patients (pts) submitted to perimitral AFl ablation guided though high-density mapping from 2015 to 2022. Pts presented either a perimitral single loop circuit or a perimitral loop with an additional loop evolving the left pulmonary veins (PV). Up to 2018, the classic IML was applied with complementary epicardial applications at operator description. Since then, a MAL was done, from the anterior mitral annulus to the left superior PV, positioned at the transition between the left atrial appendage and the anterior wall. Acute success rate was defined as conversion to sinus rhythm after completion of the ablation line.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Results: </strong>The study population included 23 pts - 11 submitted to IML and 12 to MAL – with a mean age of 65±13 and 65% male, structural cardiomyopathy in 31%, without differences between groups. Regarding AFl circuits, 8 were single-loop, 11 were dual-loop and 1 was a triple-loop. In 11/12 the outer loop involved the left PV, the other was scar-dependent with the critical isthmus localized in the left PV antrum. AFl with more than 1 loop were more commonly approached with a MAL (MAL, 73% vs IML, 27%, p = 0.005).</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">In the pts submitted to IML, additional applications in the coronary sinus were performed in 8 (73%) and lead to conversion in 4 of them. In these pts, the success rate was 55%, persisting conduction through the ablation line in the remaining.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">In the pts submitted to MAL, acute success was achieved 100%, with first-pass block being achieved in 92% (in 1 patient additional applications were done in a gap to achieve bidirectional block). Success rate was significantly higher with a MAL ablation strategy (OR: 21.2; 95%CI 1.01-445; P=0.0496), radiofrequency application time was lower (20±11 vs 65±35 min; P=0.032) and procedure duration was reduced (171±40 vs 230±73 min; P<0.001). No significant complications occurred in both groups.</span></span></p> <p><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Conclusion: </strong>A MAL is a novel and attractive alternative approach to the classic IML, increasing the effectiveness for perimitral AFl ablation.</span></span></p>
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