Effect of mitral isthmus block on development of atrial tachycardia following ablation for atrial fibrillation.

Background: Successful mitral isthmus (MI) ablation may reduce recurrence of atrial fibrillation (AF) and macro-reentrant atrial tachycardia (AT) after pulmonary vein isolation (PVI) for AF.

Objective: To determine if achieving bidirectional MI conduction block (MIB) during circumferential pulmonary vein ablation (CPVA) plus left atrial linear ablation (LALA) affects development of AT.

Methods: Sixty consecutive patients with persistent (n = 25) or paroxysmal (n = 35) AF undergoing CPVA plus LALA at the MI and LA roof were evaluated in a prospective, nonrandomized study.

Results: PVI was achieved in all patients. Bidirectional MI block was achieved in 50 of 60 patients (83%). During 18 +/- 5 months follow-up, 12 patients (20%) developed recurrent AF and 15 (25%) developed AT. Patients in whom MIB was not achieved at initial ablation had four times higher risk of developing AT (P = 0.008, 95% confidence interval 1.43-11.48) versus patients with MIB. In 12 patients with AT undergoing repeat ablation, 22 ATs were identified, with reentry involving the MI in nine, the LA roof in six, and the ridge between the LA appendage and left PVs in seven. In patients with MIB at initial ablation, recovery of MI conduction was seen in eight of 13 undergoing repeat ablation.

Conclusions: AT occurring after CPVA plus LALA is often due to incomplete MI ablation, but may also occur at the LA roof, and ridge between the LA appendage and left PVs. Failure to achieve MI block increases the risk of developing AT. Resumption of MI conduction may also be a mechanism for AT recurrence. (PACE 2010; 460-468).