Electrophysiological Characteristics of Atrial Tachycardia After Mitral Valve Surgery via a Superior Transseptal Approach
2021; Lippincott Williams & Wilkins; Volume: 14; Issue: 4 Linguagem: Inglês
10.1161/circep.120.009437
ISSN1941-3149
AutoresYasuyuki Egami, Kohei Ukita, Akito Kawamura, Hitoshi Nakamura, Yutaka Matsuhiro, Koji Yasumoto, Masaki Tsuda, Naotaka Okamoto, Akihiro Tanaka, Yasuharu Matsunaga‐Lee, Masamichi Yano, Ryu Shutta, Masami Nishino, Jun Tanouchi,
Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 14, No. 4Electrophysiological Characteristics of Atrial Tachycardia After Mitral Valve Surgery via a Superior Transseptal Approach Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUBElectrophysiological Characteristics of Atrial Tachycardia After Mitral Valve Surgery via a Superior Transseptal Approach Yasuyuki Egami, MD, Kohei Ukita, MD, Akito Kawamura, MD, Hitoshi Nakamura, MD, Yutaka Matsuhiro, MD, Koji Yasumoto, MD, Masaki Tsuda, MD, Naotaka Okamoto, MD, Akihiro Tanaka, MD, Yasuharu Matsunaga-Lee, MD, Masamichi Yano, MD, PhD, Ryu Shutta, MD, Masami Nishino, MD, PhD and Jun Tanouchi, MD, PhD Yasuyuki EgamiYasuyuki Egami https://orcid.org/0000-0001-9728-6524 Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. , Kohei UkitaKohei Ukita Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. , Akito KawamuraAkito Kawamura Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. , Hitoshi NakamuraHitoshi Nakamura Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. , Yutaka MatsuhiroYutaka Matsuhiro https://orcid.org/0000-0002-5229-6857 Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. , Koji YasumotoKoji Yasumoto Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. , Masaki TsudaMasaki Tsuda https://orcid.org/0000-0003-0370-7047 Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. , Naotaka OkamotoNaotaka Okamoto Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. , Akihiro TanakaAkihiro Tanaka Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. , Yasuharu Matsunaga-LeeYasuharu Matsunaga-Lee https://orcid.org/0000-0002-4775-8914 Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. , Masamichi YanoMasamichi Yano Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. , Ryu ShuttaRyu Shutta Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. , Masami NishinoMasami Nishino Correspondence to: Masami Nishino, MD, PhD, Division of Cardiology, Osaka Rosai Hospital, 3-1179 Nagasonecho, kita-ku, Sakai, Osaka, Japan. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0309-7023 Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. and Jun TanouchiJun Tanouchi Department of Cardiology, Osaka Rosai Hospital, Sakai, Japan. Originally published16 Apr 2021https://doi.org/10.1161/CIRCEP.120.009437Circulation: Arrhythmia and Electrophysiology. 2021;14A superior transseptal (STS) approach, one of approaches to left atrium during mitral valve (MV) surgery, can provide better visualization of the MV.1 However, the incision created by the STS approach has been shown to predispose to the development of postoperative atrial tachycardias (ATs).2 Catheter ablation of ATs after an MV surgery is frequently challenging due to complex mechanisms.2,3 The purpose of this study was to clarify the electrophysiological characteristics and ablation outcomes of ATs after MV surgery via an STS approach.The data that support the findings of this study are available from the corresponding author upon reasonable request.We retrospectively analyzed 28 consecutive patients who underwent catheter ablation of antiarrhythmic drug-refractory ATs after MV surgery via an STS approach between January 2012 and August 2019 in our institution, with at least one complete activation map using 3-dimensional electroanatomic mapping. All patients provided written informed consent for catheter ablation. This study was approved by the review board of Osaka Rosai Hospital.The methods of 3-dimensional electroanatomic mapping, postprocedural follow-up, and statistical analysis were presented in the Data Supplement.The baseline clinical characteristics and concomitant surgical procedures are shown in Table I in the Data Supplement.A total of 53 stable ATs (mean cycle length: 270 ms) were documented during the procedure (1 AT in 13 patients [46%], 2 ATs in 10 patients [36%], and ≧3 ATs in 5 patients (18%). The number of ATs per patient was 1.9±0.7 (range 1–5 ATs per patient). The completely mapped 46 ATs were shown in Figure [A].Download figureDownload PowerPointFigure. Mechanism of identified atrial tachycardias (ATs) and ablation outcomes.A, Right atrium (RA) macroreentrant ATs (N=29) included cavotricuspid isthmus (CTI)–dependent AT (①, N=14), incisional AT (②, N=10) that turned around an incisional scar, and incisional gap-related ATs (③, N=5). The left atrium (LA) macroreentrant ATs (N=11) included perimitral flutter (④, N=9 [④ a: single-loop, N=5, ④ b: dual-loop, N=4]) and roof-dependent AT (⑤, N=2). The right-sided focal ATs (⑥, N=3) originated from the tricuspid valve (TV) annulus (N=2) and lower crista terminalis (N=1). The origin of the left-sided focal ATs (⑥, N=1) was from the left superior pulmonary vein. Localized reentrant AT (⑥, N=1) was observed on the LA roof. An atrioventricular nodal reentrant tachycardia (⑦, N=1) was induced by programed stimuli. Black circles and black triangle indicate the location of focal AT and localized reentry, respectively. White arrow represents the direction of activation. The broken line indicates the incisional line. B, Kaplan-Meier curves for freedom from AT after catheter ablation (CA). C, AT recurrence and AT circuit chamber. *P=0.006: right- and left-sided ATs vs right-sided AT, †P=0.048: right- and left-sided ATs vs left-sided AT. AVNRT indicates atrioventricular nodal reentrant tachycardia; IVC, inferior vena cava; LSPV, left superior pulmonary vein; MAT, macroreentrant atrial tachycardia; MV, mitral valve; RSPV, right superior pulmonary vein; SVC, superior vena cava; and TV, tricuspid valve.Forty-three ATs (93%) were ablated successfully, but 3 ATs failed to terminate due to an incomplete linear lesion (N=1) of a roof-dependent AT and a transient atrioventricular block (N=2) during the linear ablation for cavotricuspid isthmus. No major complications occurred during the procedure. Pacemakers (N=3) were implanted for previously known sick sinus syndrome.After 27±25 months follow-up, ATs recurrences were observed in 8 patients (29%). The freedom from AT was 82% at 12 months, 76% at 24 months, and 67% at 36 months (Figure [B]). The patient background and procedural parameters with and without AT recurrence are shown in Table I in the Data Supplement. The rate of AT recurrence for patients with multiple ATs (N=17) tended to be higher than for patients with one AT (N=11) but not statistically significant (9% versus 41%, P=0.099). Patients with the right- and left-sided ATs were significantly associated with AT recurrences (Figure [C]). Five patients underwent a repeated catheter ablation because of AT recurrence. A total of 7 ATs were identified during the repeated procedure, the mechanism was cavotricuspid isthmus-dependent AT (N=1), incisional AT (N=1), perimitral flutter (N=2), left atrium focal AT (N=1), and biatrial AT (N=2; Table II in the Data Supplement). All relapsed ATs were successfully ablated.Cavotricuspid isthmus-dependent AT (Figure [A], ①) was the most frequent mechanism in this study, which was consistent with the previous studies.2,4 All incisional ATs (Figure [A], ②) were terminated by a linear ablation between the lower point of incisional line of right atrium free wall and the inferior vena cava. All incisional gap-related ATs could be terminated by ablation at the site with fractionated potentials on the incisional line (Figure [A], ③). The reason for the electrical conduction across a surgical incisional line is unknown. However, conduction across the incisional line has been demonstrated between donor and recipient hearts after heart transplants.5 Therefore, the same mechanism can be applied for the electrical conduction across an incisional line.Perimitral flutter (Figure [A], ④a,b) was the most frequent circuit in the left-sided ATs. Four out of 9 perimitral flutters exhibited a dual-loop reentry (Figure [A], ④b) with common isthmus between septal incision and MV annulus, which were ablated successfully at the isthmus.Among the 7 ATs identified during the repeated procedure, 4 ATs (nos. 2, 5, 6, and 7 in Table II in the Data Supplement) were almost identical to the previously treated ATs. The perimitral flutters of numbers 5 and 6 were successfully terminated by the ablation of mitral isthmus with the endocardial and epicardial approach. The ATs may be iatrogenic AT due to the development from the previous left septal linear ablation.Since the development of AT was related to impaired tissue resulting from a surgical procedure or underlying heart disease,2 the patients with the right- and left-sided ATs may have extensive damaged atrium. Therefore, such patients are at high risk for an AT recurrence and require close follow-up.In conclusions, this study is one of the largest case series and first report on the electrophysiological characteristics and ablation outcomes of ATs after MV surgery via the STS approach.Nonstandard Abbreviations and AcronymsATatrial tachycardiaMVmitral valveSTSsuperior transseptalAcknowledgmentsWe thank cardiovascular surgeons for interpretation of surgical procedure, Keiji Yamamoto, Atsushi Shiono, and Tomoyoshi Morioku for their technical assistance during the electrophysiological study and John Martin for his linguistic assistance with this article.Sources of FundingNone.Supplemental MaterialsData Supplement MethodsData Supplement Tables I–IIDisclosures None.FootnotesFor Sources of Funding and Disclosures, see page 456.The Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCEP.120.009437.Correspondence to: Masami Nishino, MD, PhD, Division of Cardiology, Osaka Rosai Hospital, 3-1179 Nagasonecho, kita-ku, Sakai, Osaka, Japan. Email [email protected]johas.go.jpReferences1. Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve.Ann Thorac Surg. 1991; 52:1058–60; discussion 1060. doi: 10.1016/0003-4975(91)91281-yCrossrefMedlineGoogle Scholar2. Lukac P, Hjortdal V, Pedersen AK, Jensen HK, Mortensen PT, Hansen PS. The superior transseptal surgical approach to mitral valve creates slow conduction.Pacing Clin Electrophysiol. 2006; 29:719–726. doi: 10.1111/j.1540-8159.2006.00425.xCrossrefMedlineGoogle Scholar3. Markowitz SM, Brodman RF, Stein KM, Mittal S, Slotwiner DJ, Iwai S, Das MK, Lerman BB. Lesional tachycardias related to mitral valve surgery.J Am Coll Cardiol. 2002; 39:1973–1983. doi: 10.1016/s0735-1097(02)01905-8CrossrefMedlineGoogle Scholar4. Enriquez A, Santangeli P, Zado ES, Liang J, Castro S, Garcia FC, Schaller RD, Supple GE, Frankel DS, Callans DJ, et al.. Postoperative atrial tachycardias after mitral valve surgery: mechanisms and outcomes of catheter ablation.Heart Rhythm. 2017; 14:520–526. doi: 10.1016/j.hrthm.2016.12.002CrossrefMedlineGoogle Scholar5. Saoudi N, Redonnet M, Anselme F, Poty H, Cribier A. Catheter ablation of atrioatrial conduction as a cure for atrial arrhythmia after orthotopic heart transplantation.J Am Coll Cardiol. 1998; 32:1048–1055. doi: 10.1016/s0735-1097(98)00360-xCrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails April 2021Vol 14, Issue 4Article InformationMetrics Download: 202 © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.120.009437PMID: 33858177 Originally publishedApril 16, 2021 Keywordsmitral valveelectrophysiologycatheter ablationarrhythmiaatrial fluttertreatment outcomePDF download SubjectsElectrophysiology
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