Mapping and ablation of clinical spontaneous perimitral atrial tachycardias using an ultra–high-resolution mapping system

Published:September 29, 2020DOI:


      Perimitral atrial tachycardias (PMATs) are common atrial tachycardias (ATs), yet their mechanisms vary.


      The purpose of this study was to characterize clinical spontaneous PMATs using an ultra–high-resolution (UHR) mapping system.


      The study included 32 consecutive PMATs in 31 patients who had undergone AT mapping/ablation using a UHR mapping system.


      Six, 10, 11, and 5 PMATs occurred in cardiac intervention-naïve (group A), post-lateral/posterior mitral isthmus linear ablation (group B), post-atrial fibrillation ablation without mitral isthmus linear ablation (group C), and post-cardiac surgery (group D) patients, respectively. Group A patients tended to be older, more likely were female, and had sinus node or atrioventricular conduction disturbances more frequently. A 12-lead synchronous isoelectric interval was observed in 15 PMATs (46.9%). Coronary sinus activation was proximal to distal or distal to proximal except in 3 PMATs with straight patterns due to epicardial gaps. Left atrial anterior/septal wall (LAASW) low-voltage areas were smallest in group B. Slow conduction areas (SCAs) were identified in 26 PMATs (81.2%) and were located on the LAASW in all group A and group D patients. Conduction velocity in the SCAs was slowest in group B. In group B, all PMATs were terminated by single applications, and the gaps were located epicardially in 5 of 10 (50%). Anterior (n = 23) or lateral/posterior (n = 9) mitral isthmus linear block was successfully created without any complications in all. Twenty-five concomitant ATs among 18 patients (58.1%) also were eliminated. During a median of 20.0 (11.0–40.0) months of follow-up, 28 patients (90.3%) were free from any atrial tachyarrhythmias.


      An UHR mapping-guided approach with identification of the individual tachycardia mechanism should be the preferred strategy given the distinct and complex arrhythmia mechanisms.

      Graphical abstract


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Shah A.J.
        • Jadidi A.
        • Liu X.
        • et al.
        Atrial tachycardias arising from ablation of atrial fibrillation: a proarrhythmic bump or an antiarrhythmic turn?.
        Cardiol Res Pract. 2010; 2010: 950763
        • Jaïs P.
        • Matsuo S.
        • Knecht S.
        • et al.
        A deductive mapping strategy for atrial tachycardia following atrial fibrillation ablation: importance of localized reentry.
        J Cardiovasc Electrophysiol. 2009; 20: 480-491
        • Mantziari L.
        • Butcher C.
        • Kontogeorgis A.
        • et al.
        Utility of a novel rapid high-resolution mapping system in the catheter ablation of arrhythmias: an initial human experience of mapping the atria and the left ventricle.
        JACC Clin Electrophysiol. 2015; 1: 411-420
        • Laţcu D.G.
        • Bun S.S.
        • Viera F.
        • et al.
        Selection of critical isthmus in scar-related atrial tachycardia using a new automated ultrahigh resolution mapping system.
        Circ Arrhythm Electrophysiol. 2017; 10e004510
        • Pathik B.
        • Lee G.
        • Nalliah C.
        • et al.
        Entrainment and high-density three-dimensional mapping in right atrial macroreentry provide critical complementary information: entrainment may unmask "visual reentry" as passive.
        Heart Rhythm. 2017; 14: 1541-1549
        • Rostock T.
        • O'Neill M.D.
        • Sanders P.
        • et al.
        Characterization of conduction recovery across left atrial linear lesions in patients with paroxysmal and persistent atrial fibrillation.
        J Cardiovasc Electrophysiol. 2006; 17: 1106-1111
        • Vlachos K.
        • Denis A.
        • Takigawa M.
        • et al.
        The role of Marshall bundle epicardial connections in atrial tachycardias after atrial fibrillation ablation.
        Heart Rhythm. 2019; 16: 1341-1347
        • Sawhney N.
        • Anand K.
        • Robertson C.E.
        • Wurdeman T.
        • Anousheh R.
        • Feld G.K.
        Recovery of mitral isthmus conduction leads to the development of macro-reentrant tachycardia after left atrial linear ablation for atrial fibrillation.
        Circ Arrhythm Electrophysiol. 2011; 4: 832-837
        • Miyazaki S.
        • Shah A.J.
        • Hocini M.
        • Haïssaguerre M.
        • Jaïs P.
        Recurrent spontaneous clinical perimitral atrial tachycardia in the context of atrial fibrillation ablation.
        Heart Rhythm. 2015; 12: 104-110
        • Marcus G.M.
        • Yang Y.
        • Varosy P.D.
        • et al.
        Regional left atrial voltage in patients with atrial fibrillation.
        Heart Rhythm. 2007; 4: 138-144
        • Barkagan M.
        • Shapira-Daniels A.
        • Leshem E.
        • Shen C.
        • Anter E.
        Pseudoblock of the posterior mitral line with epicardial bridging connections is a frequent cause of complex perimitral tachycardias.
        Circ Arrhythm Electrophysiol. 2019; 12e006933
        • Lehrmann H.
        • Jadidi A.S.
        • Minners J.
        • et al.
        Novel electrocardiographic criteria for real-time assessment of anterior mitral line block: "V1 jump" and "V1 delay.
        JACC Clin Electrophysiol. 2018; 4: 920-932
        • Shah A.J.
        • Pascale P.
        • Miyazaki S.
        • et al.
        Prevalence and types of pitfall in the assessment of mitral isthmus linear conduction block.
        Circ Arrhythm Electrophysiol. 2012; 5: 957-967
        • Pascale P.
        • Shah A.J.
        • Roten L.
        • et al.
        Pattern and timing of the coronary sinus activation to guide rapid diagnosis of atrial tachycardia after atrial fibrillation ablation.
        Circ Arrhythm Electrophysiol. 2013; 6: 481-490
        • Shah D.
        ECG manifestations of left atrial flutter.
        Curr Opin Cardiol. 2009; 24: 35-41