Radiofrequency Ablation of Atrial Fibrillation in Patients With Mechanical Mitral Valve Prostheses

• Published in: Journal of the American College of Cardiology Vol. 58; no. 6; pp. 596 - 602
• Main Authors: Hussein, Ayman A., MD, Wazni, Oussama M., MD, Harb, Serge, MD, Joseph, Lee, MD, Chamsi-Pasha, Mohammed, MD, Bhargava, Mandeep, MD, Martin, David O., MD, Dresing, Thomas, MD, Callahan, Thomas, MD, Kanj, Mohamed, MD, Natale, Andrea, MD, Lindsay, Bruce D., MD, Saliba, Walid I., MD
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 02.08.2011
• Subjects: atrial fibrillation; Cardiovascular; Internal Medicine; mitral valve prostheses; radiofrequency ablation; PVI; atrial flutter; intracardiac echocardiography; AFL; MVR; interquartile range; INR; international normalized ratio; atrial fibrillation; MA; sinus rhythm; cavotricuspid isthmus; left atrium; SR; AF; ICE; mitral annulus; IQR; pulmonary vein isolation; atrial tachycardia; RA; AT; LA; right atrium; mitral valve prostheses; CTI; radiofrequency ablation; mitral valve replacement
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2011.03.039

Objectives The purpose of this study was to evaluate the feasibility, safety, and outcomes of radiofrequency ablation of atrial fibrillation (AF) in patients with mechanical mitral valve replacement (MVR). Background The role of ablative therapy in patients with MVR is not yet established, with safety concerns and very few outcome data. Methods Between January 2003 and December 2008, we followed up 81 patients with MVR undergoing first-time AF ablation (compared with 162 age- and sex-matched controls). Arrhythmia recurrences were identified by symptoms with documentation, event monitoring, Holter monitoring, and electrocardiograms. Results All MVR and control patients underwent ablation under therapeutic international normalized ratio. No entrapment of catheters or stroke occurred. There were no differences in terms of procedure-related complications between the groups (p = NS). Patients with MVR had larger atria (p < 0.0001), lower left ventricular ejection fractions (p = 0.0001), and more concomitant atrial flutter at baseline (p < 0.0001). Over a 24-month follow-up, they had higher recurrence rates compared with controls (49.4% vs. 27.7% after a single ablation, p = 0.0006). The creation of flutter lines significantly reduced recurrences in patients with any history of atrial flutter (16.7% vs. 60.9%, p = 0.009). At last follow-up, 82.7% of MVR patients had their arrhythmia controlled (69.1% not receiving antiarrhythmic drugs). Conclusions Radiofrequency ablation is feasible and safe for patients with MVR. It allowed restoration of sinus rhythm in a substantial proportion of patients undergoing ablation. An abnormal atrial substrate underlies recurrences in these patients. The ablation procedure needs to be further refined with a focus on extra pulmonary vein triggers and concomitant flutters to improve outcomes.