Key result
Mitral isthmus ablation faces challenges from epicardial connections, while alcohol alternatives risk impaired atrial systole.
Why the study?
Mitral isthmus-dependent atrial flutter often occurs after atrial fibrillation ablation and achieving conduction block at the mitral isthmus is challenging due to residual epicardial connections.
Highlights the challenges of treating mitral isthmus-dependent atrial flutter and the potential anatomical and mechanical risks associated with alternative treatments like ethanol infusion.
May support alternative strategies in refractory MI-dependent AFL; leaves open need for prospective validation before adoption.
Mitral isthmus (MI)-dependent atrial flutter (AFL) often occurs after catheter ablation of atrial fibrillation.1 Linear ablation across the MI is the first line treatment for this AFL. However, achievement of conduction block at the MI is challenging because of residual epicardial connections. When linear ablation at the MI fails to treat the AFL, subsequent treatment options may include alcohol ablation through the vein of Marshall,2 anterior mitral line ablation,3 or septal line ablation4. However, the extent of lesion formation after ethanol infusion into the vein of Marshall cannot be precisely predicted, raising concerns about potential impairment of mechanical atrial systole and inadvertent isolation of the left atrial appendage.
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Yamada et al. (2026) conducted a review in Mitral isthmus-dependent atrial flutter. Catheter ablation strategies (e.g., linear ablation, alcohol ablation) was evaluated. Linear ablation across the mitral isthmus is challenging due to residual epicardial connections, and alternative options like alcohol ablation raise concerns about impaired mechanical atrial systole.
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