Catheter Ablation for Peri-Mitral Atrial Flutter Post Mitral Valve Replacement

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Peri-mitral atrial flutter (PMFL) may occur in patients with prior mitral valve replacement (MVR). Catheter ablation (CA) may be challenging owing to prosthetic valve and the surrounding scar. A 61 year-old man underwent MVR and LA maze procedure in 2005. He was admitted to our hospital in 2011 because of atrial flutter (AFL). CA for AFL was performed. In EPS findings, PV-LA connections were isolated by prior maze procedure. CARTO mapping during tachycardia (CL=290 msec), and revealed PMFL. Radiofrequency application with an irrigated-tip catheter using Agilis sheath at the mitral isthmus successfully eliminated this tachycardia. We confirmed the MI block line by the sequence of CS activation while pacing from the LAA, but the MI block line was incomplete. The activation map on the CARTO system during LAA pacing revealed early activation site with a fractionated potential near the MI (LAA pacing site to ABL distal pole interval was 80 ms). The bidirectional conduction block line was created in the MI by additional RF current application at this conduction gap. The interval from the LAA pacing site to CS distal pole prolonged from 130 msec to 230 msec. This case report highlights the rare case of successful CA for PMFL in a patient with prior MVR.

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