Simultaneous pulmonary vein isolation and ablation of the substrate of biatrial flutter in a patient with a mechanical mitral valve prosthesis: a case report

Catheter radiofrequency ablation of the atrial fibrillation substrate may be difficult in patients after open heart surgery. Difficulties may arise in the presence of a mitral valve prosthesis, atrial arrhythmias of several morphologies (more often left atrial atypical flutter), including incisional ones. These cases require a thorough and scrupulous approach to achieve complete isolation of all available arrhythmia substrates. A distinctive feature of this observation is the successful simultaneous pulmonary vein isolation and two atrial arrhythmias in a patient with a mechanical mitral prosthesis.

1. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021;42(5): 373-498. https://doi.org/10.1093/eurheartj/ehaa612.

2. Zipse MM, Nguyen DT. Ablation of Atrial Fibrillation in a Patient with a Mechanical Mitral Valve. Card Electrophysiol Clin. 2016;8(1): 155-159. https://doi.org/10.1016/j.ccep.2015.10.017.

3. Santangeli P, DI Biase L, Bai R, et al. Advances in Catheter Ablation: Atrial Fibrillation Ablation in Patients With Mitral Mechanical Prosthetic Valve. Curr Cardiol Rev. 2012;8(4): 362-367. https://doi.org/10.2174/157340312803760767.

4. Alkhouli M, Rihal CS, Holmes DR. Transseptal Techniques for Emerging Structural Heart Interventions. JACC Cardiovasc Interv. 2016;9(24): 2465-2480. https://doi.org/10.1016/j.jcin.2016.10.035.

5. Sheldon S.H., Good E. PentaRay entrapment in a mechanical mitral valve during catheter ablation of atrial fibrillation. Hear Rhythm Case Rep. 2016;2: 200-201. https://doi.org/10.1016/j.hrcr.2015.11.006.

6. Lakkireddy D, Nagarajan D, Di Biase L, et al. Radiofrequency ablation of atrial fibrillation in patients with mitral or aortic mechanical prosthetic valves: A feasibility, safety, and efficacy study. Heart Rhythm. 2011;8(7): 975-980. https://doi.org/10.1016/j.hrthm.2011.02.012.

7. Tatarskiy R, Garkina S, Lebedev D. Catheter Ablation of Incisional Atrial Tachycardia. J Atr Fibrillation. 2016;9(3): 1476. https://doi.org/10.4022/jafib.1476.

8. Cosío FG. Atrial Flutter, Typical and Atypical: A Review. Arrhythmia Electrophysiol Rev. 2017;6(2): 55. https://doi.org/10.15420/aer.2017:5:2.

9. Zipse MM, Nguyen DT. Ablation of Atrial Fibrillation in a Patient with a Mechanical Mitral Valve. Cardiac Electrophysiology Clinics. 2016;8(1): 155-159. https://doi.org/10.1016/j.ccep.2015.10.017.