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Lesional tachycardias related to mitral valve surgery

Steven M. Markowitz, MD, FACC^*, Richard F. Brodman, MD, FACC, Kenneth M. Stein, MD, FACC^*, Suneet Mittal, MD, FACC^*, David J. Slotwiner, MD^*, Sei Iwai, MD^*, Mithilesh K. Das, MD^* and Bruce B. Lerman, MD, FACC^*,*

^* Division of CardiologyThe New York Hospital-Cornell University Medical Center, New York, New York, USA
Cardiothoracic Surgery, The New York Hospital-Cornell University Medical Center, New York, New York, USA

View larger version (83K): [in a new window]   Figure 1 Atrial incisions for mitral valve surgery. (A) The standard right lateral left atriotomy involves an incision in the left atrium (LA) anterior to the right superior and inferior pulmonary veins (RSPV, RIPV). (B) A modification of this approach is dissection in the interatrial groove, with an incision posterior to the fossa ovalis. (C1 and C2) The superior trans-septal approach involves an atriotomy in the lateral wall of the right atrium (RA), which is extended over the superior RA, the septum and the dome of the LA (C1). Cannulae are indicated in the inferior vena cava, superior vena cava or the right atrial appendage, as well as for retrograde cardioplegia via the coronary sinus.

View larger version (41K): [in a new window]   Figure 2 Electroanatomic maps acquired during tachycardia in Patient 3, who had a superior trans-septal approach for mitral valve replacement. (A) Bipolar voltage maps of both atria in a cranial projection. A zone of low voltage is present in the lateral wall of the right atrium (RA), extending superiorly and along the atrial septum. Low voltage is also present in the septal wall and the dome of the left atrium (LA). The blue tag indicates a site of double potentials, and pink tags are fractionated potentials. (B) Isochronal activation map of the RA, in a right anterior oblique projection (isochronal step = 20 ms). The gray area indicates a region of low voltage, and the double brown lines indicate a line of conduction block in the lateral wall. A single re-entrant circuit is present around the lateral wall of the RA involving tissue between scar and the superior vena cava (SVC). This circuit involves tissue with low voltage and fractionated potentials adjacent to the SVC. IVC = inferior vena cava; LSPV = left superior pulmonary vein; RAA = right atrial appendage.

View larger version (29K): [in a new window]   Figure 3 Right atrial electroanatomic maps acquired during tachycardia in Patient 1, who had an incision in the interatrial groove, followed by reoperation with the superior trans-septal approach. (A) Bipolar voltage map of the right atrium in a right posterolateral projection. A zone of low voltage is present in the lateral wall of the right atrium, extending to the superior vena cava (SVC) and the inferior vena cava. Tag colors are those used in Figure 2. The green tag (x) is a site of concealed entrainment where ablation terminated atrial tachycardia. At this site, the stimulus to P-wave interval during pacing was identical to the electrogram to P-wave during tachycardia (125 ms). (B) Isochronal activation map. Figure-of-eight re-entry is present, with a common isthmus between two lesions in the lateral wall.

View larger version (59K): [in a new window]   Figure 4 Left atrial electroanatomic maps acquired during tachycardia in Patient 7, who had a left atriotomy. (A) Voltage map in the right lateral projection. An extensive region of low voltage is present in the posteroseptal wall adjacent to the right pulmonary veins. (B) Surface leads I, aVF and V1 and intracardiac recordings from the His bundle (HB) and coronary sinus (CS) during atrial tachycardia. Coronary sinus activation is earliest at the posterior mitral annulus (CS pole 5 to 6). (C and D) Isochronal maps in the right lateral and anteroposterior projections. Re-entry occurs around the posteroseptal lesion and right pulmonary veins, with a zone of slow conduction and low amplitude electrograms in the roof of the left atrium. The right superior pulmonary vein (RSPV), left superior pulmonary vein (LSPV) and left inferior pulmonary vein (LIPV) are identified. The wavefront bifurcates at the posterior aspect of the mitral annulus, which explains early CS activation in CS pole 5 to 6. MV = mitral valve.

View larger version (32K): [in a new window]   Figure 5 Left atrial activation maps acquired during tachycardia in Patient 6, who had a left atriotomy. (A) Posteroanterior (PA) projection, which demonstrates a re-entrant loop around an area of low voltage in the posterior wall. (B) Anteroposterior (AP) view of the same tachycardia, demonstrating a second limb of the circuit involving the mitral annulus. A bystander region is present between the mitral annulus and an area of low voltage in the septum with wavefront collision (double lines). MV = mitral valve.

View larger version (43K): [in a new window]   Figure 6 Schematic representation of atrial tachycardias mapped in the right atrium (RA), depicting macro–re-entrant circuits, focal tachycardias and passive activation of the RA during left atrial tachycardias. The patient numbers are identified, as are the surgical approaches to the mitral valve. The projections include right lateral (RL), right anterior oblique (RAO), anteroposterior (AP) and posteroanterior (PA) views. Gray areas indicate zones of low amplitude potentials. Also identified are the crista terminalis (CT) and coronary sinus (CS). Blue tags represent double potentials, and pink tags are fractionated potentials. Sites marked with x indicate concealed entrainment with a postpacing interval 10 ms longer than the atrial tachycardia cycle length. Green lines represent the direction of activation, and green stars denote the origin of focal tachycardias. During left atrial tachycardias, activation of the RA occurs via the low septal RA or Bachmann’s bundle. IVC = inferior vena cava; SVC = superior vena cava; TV = tricuspid valve.

View larger version (36K): [in a new window]   Figure 7 Schematic representation of atrial tachycardias mapped in the left atrium depicting macro–re-entrant circuits, a focal tachycardia and passive activation of the left atrium during a right atrial tachycardia. Color codes and projections are the same as Figure 5. MV = mitral valve; PA = posteroanterior; RAO = right anterior oblique; RL = right lateral; RSPV = the right superior pulmonary vein.