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Mitral isthmus ablation: A hierarchical approach guided by electroanatomic correlation

Published:October 09, 2018DOI:https://doi.org/10.1016/j.hrthm.2018.10.005
      Mitral isthmus ablation is an established technique used to treat perimitral atrial flutter. The classic approach involves creating an ablation line connecting the left inferior pulmonary vein (LIPV) to the lateral mitral annulus.
      • Jais P.
      • Hocini M.
      • Hsu L.F.
      • et al.
      Technique and results of linear ablation at the mitral isthmus.
      Its feasibility was first prospectively studied by Jais et al,
      • Jais P.
      • Hocini M.
      • Hsu L.F.
      • et al.
      Technique and results of linear ablation at the mitral isthmus.
      who reported a high rate of bidirectional block. However, subsequent studies by the same group, as well as others, have been less promising.
      • Hocini M.
      • Shah A.J.
      • Nault I.
      • et al.
      Mitral isthmus ablation with and without temporary spot occlusion of the coronary sinus: a randomized clinical comparison of acute outcomes.
      This is important because failure to achieve bidirectional block with ablation has been shown to be proarrhythmic.
      • Knecht S.
      • Hocini M.
      • Wright M.
      • et al.
      Left atrial linear lesions are required for successful treatment of persistent atrial fibrillation.
      Therefore, it is essential that bidirectional block be achieved whenever mitral isthmus ablation is attempted. This review addresses potential pitfalls of mitral isthmus ablation using electroanatomic correlation and describes our stepwise hierarchical approach to achieving bidirectional block.

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