Biatrial tachycardia following linear anterior wall ablation for the perimitral reentry: incidence and electrophysiological evaluations

Abstract

Introduction: A left atrial (LA) anterior ablation line (AnL), connecting the mitral annulus and right pulmonary veins or a roof line, has been suggested as an alternative to mitral isthmus (MI) ablation for perimitral flutter (PMF). Theoretically, the AnL can exclude the LA septal wall from the reentrant circle, and lead to involvement of the right atrium (RA) in a tachycardia (AT) mechanism.

Methods and results: Among 807 patients undergoing atrial fibrillation ablation, PMF was diagnosed in 28 subjects, and AnL was performed in 13, and MI ablation in 15 cases. In 4 (31%) patients, AnL resulted in abrupt AT cycle length prolongation, which was associated with the development of a clockwise biatrial tachycardia (bi-AT). The bi-AT propagated along the lateral and posterior mitral annulus, entered the RA via the coronary sinus, and after activating the RA septum reentered the LA over the Bachmann's bundle. The bi-AT was terminated by ablation in Bachmann's bundle insertion areas in the RA or LA. No bi-AT was documented in the MI group. One patient in the AnL group died of stroke in 10 days following the procedure. Anatomic evaluation showed that at the level of the AnL the RA anteroseptal area was separated from the LA by the aortic root, and was free from ablation damage.

Conclusion: A bi-AT can develop when an AnL is created for PMF termination. Biatrial entrainment mapping facilitates diagnosis. Termination of the bi-AT is feasible when ablated from either RA or LA.

Keywords: Bachmann's bundle; atrial fibrillation; atrial tachycardia; catheter ablation; left atrial flutter; perimitral reentry.