Right septal macroreentrant tachycardia late after mitral valve repair: Importance of surgical access approach

doi:10.1016/j.hrthm.2006.09.032

Heart Rhythm

Volume 4, Issue 1, January 2007, Pages 32-36

https://doi.org/10.1016/j.hrthm.2006.09.032 Get rights and content

Background

Reentrant atrial tachycardias may occur after mitral valve surgery. These usually involve the left atrium or the lateral wall of the right atrium around the atriotomy scar.

Objective

The purpose of this study was to test whether ablation could eliminate atrial tachycardia after mitral valve repair.

Methods

Three patients (two men, one woman; mean age 57 ± 12 years) were studied 48 ± 38 months after mitral valve repair. In all cases, the surgical approach involved a transseptal incision. Tachycardia mapping was performed using multipolar catheters and the three-dimensional electroanatomic mapping system. The mean flutter cycle length was 313 ± 21 ms. All patients had dual-loop reentry with one circuit around a septal scar and the other circuit around the tricuspid annulus.

Results

Successful radiofrequency ablation of the septal circuit was performed between the scar and the superior tricuspid annulus in all three cases.

Conclusion

After mitral valve repair using a transseptal incision, dual-loop reentry may occur around the septal scar and the tricuspid annulus. Successful ablation may be achieved with an ablation line between the scar and the tricuspid annulus.

Section snippets

Methods

Between August 2004 and July 2006, three patients with a septal reentry circuit after mitral valve repair were investigated. The two men and one woman, with a mean age of 57 ± 12 years, underwent mitral valve repair 48 ± 38 months before electrophysiological study. The surgical approach varied between patients (see Table 1), however, in every case the surgery involved a transseptal incision. The patients had previously undergone 2 ± 1 cardioversions and had failed 2.3 ± 0.6 antiarrhythmic

Results

At the electrophysiological study, all patients were in incessant tachycardia with a mean cycle length of 315 ± 18 ms. The flutter wave morphology of the three patients is demonstrated in (Figures 1A,2A, and 3A). In each patient, a detailed electroanatomic map (mean 145 ± 71 points) was obtained during the tachycardia (Figures 1B, 2B).

In all cases, activation and entrainment mapping demonstrated the presence of a circuit around a scar on the septum and a simultaneous cavotricuspid

Discussion

There are a number of approaches to accessing the left atrium for mitral valve surgery. These include the right lateral left atriotomy, dissection in the interatrial groove, and the superior transseptal approach. Reentrant circuits have been described in relation to each of these approaches.³ A less common approach is a right atriotomy followed by a septal incision, as was performed in the third patient in this report. In an elegant study, Markowitz et al³ demonstrated a number of different

Conclusion

After mitral valve surgery with a transseptal incision, right septal tachycardia may occur with the septal scar functioning as the central barrier. This circuit commonly coexists with a simultaneous peri-tricuspid annular circuit. Successful ablation may be achieved with a line between the scar and the tricuspid annulus.

References (7)

S.M. Markowitz et al.
Lesional tachycardias related to mitral valve surgery
J Am Coll Cardiol
(2002)
J.M. Kalman et al.
Ablation of “incisional” reentrant atrial tachycardia complicating surgery for congenital heart diseaseUse of entrainment to define a critical isthmus of conduction
Circulation
(1996)
D. Shah et al.
Dual-loop intra-atrial reentry in humans
Circulation
(2000)

There are more references available in the full text version of this article.

Cited by (17)

Interpretation of Typical and Atypical Atrial Flutters by Precision Electrocardiology Based on Intracardiac Recording
2022, Cardiac Electrophysiology Clinics
Citation Excerpt :
The RA often constitutes the initial surgical access to the other cardiac chambers, and it is a convenient way to provide venous access during circulatory bypass. Most resultant RA surgical scars, due to these procedure, are located in the anterior wall and the septum and not infrequently become the substrate of macroreentry.44 Furthermore, the RA anatomy predisposes this chamber to develop spontaneous isthmus-dependent flutter, and this propensity is accentuated by the addition of new surgically induced barriers.45
Macroreentrant biatrial tachycardia relevant to interatrial septal incisions after mitral valve surgery: Electrophysiological characteristics and ablation strategy
2020, Heart Rhythm
Citation Excerpt :
After mitral valve (MV) surgery, a considerable proportion of patients may present with macroreentrant atrial tachycardia (AT).1,2
Macroreentrant biatrial tachycardia (BiAT) associated with interatrial septal incisions after mitral valve (MV) surgery has been rarely reported.
The purpose of this study was to assess the mapping and ablation strategy of this special category of atrial tachycardia (AT).
We identified 10 BiATs from a total of 84 ATs after MV surgery performed at 3 institutions. Activation maps for both the right atrium (RA) and left atrium (LA) were obtained using an ultrahigh-density mapping system. We also performed entrainment pacing from multiple LA and RA site within the speculative circuit.
By analyzing activation and propagation maps of both atria, we classified the circuit into 3 distinct types. In all types, posteroinferior interatrial connections act as a critical limb that, combined with other interatrial connections (Bachmann bundle, fossa ovalis, and coronary sinus ostium in 3 types, respectively), complete the circuit of BiATs. Most ATs (8/10) were terminated targeting the RA and LA end of posteroinferior interatrial connection sites.
Ultrahigh-density mapping provides a detailed description of the macroreentrant circuit of BiAT associated with interatrial septal incisions. Posteroinferior interatrial connections were essential for the circuit and should be the preferred target for ablation.
Ablation of Nonisthmus-Dependent Flutters and Atrial Macroreentry
2019, Catheter Ablation of Cardiac Arrhythmias
Atypical atrial flutters refer to a spectrum of arrhythmias that vary in location and circuit dimensions. These arrhythmias are often recognized after catheter ablation or surgical treatment of atrial fibrillation (AF) or after surgery that involves a right or left atriotomy. Atypical atrial flutter requires fixed or functional barriers and regions of slow conduction. Activation mapping is used to demonstrate reentrant circuits, middiastolic potentials, fractionated potentials, and double potentials. Electroanatomic mapping systems and multipolar electrode catheters are useful in most cases. Difficulties may arise in defining complex reentrant circuits, spontaneous conversion to other atrial arrhythmias, and achieving durable lines of block in the atrium.
The effect of surgical access for mitral valve surgery on incidence of atrial fibrillation and atrioventricular block
2017, Cor et Vasa
Citation Excerpt :
Authors localized reentry circuit in the right atrium in 56%, in the mitral annulus in 21%, in the incision of the right atrium in 16%, in the roof of the atrium in 12% and in the left atrium in 5% of patients [19]. Other works reported reentry circuit in the septal scar, in the annulus of the tricuspid valve and in the right atrium scar if transseptal access was used [20,21]. Hosseinpour et al. presented a full-thickness suture line on the intact wall of right atria from the atriotomy incision to the inferior vena cava (a natural conduction barrier) as a technique to prevent macroreentry in the right atrium scar [21].
Atrial fibrillation and conduction disorders are very common and severe postoperative complications in heart surgery.
Retrograde analysis of patients (n = 103) who had undergone mitral valve surgery or concomitant mitral and tricuspid valve surgery was performed (from January 2006 to December 2016). Patients from each group were divided into two groups: a subgroup with surgery access through the right atrium and interatrial septum (transseptal access) and a subgroup with surgery access through the left atrium (left atrial access). The following data were recorded for all patients: age, sex, extracorporeal circulation time, aortic clamping time, blood loss after surgery, count of blood transfusions administered, the need for surgical revision because of higher blood loss and postoperative atrial and atrioventricular conduction defect (atrial fibrillation and atrioventricular block with pacemaker implantation).
A statistically significant difference in extracorporeal circulation time (p < 0.05) and aortic clamping time (p < 0.01) was recorded between transseptal access and left atrial and right atrial access separately, if combined surgery of both atrioventricular valves was performed. No other statistically significant differences were recorded between the groups.
In general, the choice of surgical access for mitral valve on incidence of postoperative atrial and atrioventricular conduction disorders showed no effect. Both access through the right atrium and interatrial septum and access through the left atrium have a similar incidence of postoperative atrial fibrillation and atrioventricular block.
Abnormal atrial strain with speckle-tracking echocardiography predicts the arrhythmic substrate of atypical right atrial flutter
2017, HeartRhythm Case Reports
Citation Excerpt :
Atypical atrial flutter is defined as macroreentrant atrial tachycardia (AT) that does not involve the cavotricuspid isthmus; a variety of reentrant circuits may include reentry around the mitral valve annulus or scar tissue within the left and right atrium (RA).1 Atypical RA flutter was observed in patients who had undergone prior cardiac surgery for obvious structural heart disease.2–4 In recent years, a few reports have described atypical RA flutter in patients without obvious structural heart disease or previous cardiac surgery.5–7
Typical and Atypical Atrial Flutter: Mapping and Ablation
2014, Cardiac Electrophysiology: From Cell to Bedside: Sixth Edition

View all citing articles on Scopus

¹: Kurt Roberts-Thomson is the recipient of a Postgraduate Research Scholarship from the National Health and Medical Research Council of Australia.

View full text

Original-clinicalRight septal macroreentrant tachycardia late after mitral valve repair: Importance of surgical access approach

Background

Objective

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusion

J Am Coll Cardiol

Ablation of “incisional” reentrant atrial tachycardia complicating surgery for congenital heart diseaseUse of entrainment to define a critical isthmus of conduction

Circulation

Dual-loop intra-atrial reentry in humans

Circulation

Original-clinical
Right septal macroreentrant tachycardia late after mitral valve repair: Importance of surgical access approach