European Heart Journal Advance Access originally published online on January 6, 2005
European Heart Journal 2005 26(7):689-695; doi:10.1093/eurheartj/ehi095
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Where to draw the mitral isthmus line in catheter ablation of atrial fibrillation: histological analysis
1Heart Lung Center Utrecht, University Medical Center E03-406, PO Box 85500, 3508 GA, Utrecht, The Netherlands
2University Medical Center Utrecht, Department of Pathology, Utrecht, The Netherlands
3University Medical Center Utrecht, Department of Radiology, Utrecht, The Netherlands
4Department of Paediatrics, National Heart and Lung Institute, and Royal Brompton Hospital, London, UK
Received 6 October 2004; revised 6 October 2004; accepted 25 November 2004; online publish-ahead-of-print 6 January 2005.
* Corresponding author. E-mail address: fredwittkampf{at}mac.com
Aims A linear lesion between the left inferior pulmonary vein orifice and mitral annulus, the so-called mitral isthmus, may improve the success of catheter ablation for atrial fibrillation. Gaps in the lesion line, however, may facilitate left atrial flutter. The aim of the study was to determine the optimal location of the lesion line by serial sectioning of the isthmus area.
Methods and results In a post-mortem study of 16 patients with normal left atria, serial sections of the isthmus area from 10 mm superior to and 30 mm inferior to the isthmus were studied by light microscopy. The length of the isthmus was 35±7 mm. On average, the muscle sleeve around the coronary sinus ended 10 mm inferior to the isthmus. The prevalence of a ramus circumflexus <5 mm from the endocardial surface, decreased from 60% in the most superior section to 0% in the most inferior section. Atrial arteries were frequently present in all sections.
Conclusions The thickness of atrial myocardium, the ramus circumflexus sometimes very close to the endocardium, a myocardial sleeve around the coronary sinus, and local cooling by atrial arteries and veins may complicate the creation of conduction block in the mitral isthmus.
Key Words: Atrial fibrillation • Catheter ablation
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