The L-Line: A novel approach to treat atrial tachycardia by catheter ablation in patients after orthotopic biatrial heart transplantation

https://doi.org/10.1007/s00392-024-02526-y

Moneeb Khalaph (Bad Oeynhausen)1, C. Sohns (Bad Oeynhausen)1, D. Guckel (Bad Oeynhausen)1, G. Imnadze (Bad Oeynhausen)1, P. Lucas (Bad Oeynhausen)1, T. Fink (Bad Oeynhausen)1, V. Nesapiragasan (Bad Oeynhausen)1, V. Sciacca (Bad Oeynhausen)1, M. Braun (Bad Oeynhausen)1, J. Fleischhauer (Bad Oeynhausen)2, R. Schramm (Bad Oeynhausen)2, A. Costard-Jäckle (Bad Oeynhausen)2, H. Fox (Bad Oeynhausen)3, J. Gummert (Bad Oeynhausen)2, M. Mörsdorf (Bad Oeynhausen)1, M. Didenko (Bad Oeynhausen)1, P. Sommer (Bad Oeynhausen)1, M. El Hamriti (Bad Oeynhausen)1

1Herz- und Diabeteszentrum NRW Klinik für Elektrophysiologie/ Rhythmologie Bad Oeynhausen, Deutschland; 2Herz- und Diabeteszentrum NRW Klinik für Thorax- und Kardiovaskularchirurgie Bad Oeynhausen, Deutschland; 3Herz- und Diabeteszentrum NRW Zentrum für Herzinsuffizienz Bad Oeynhausen, Deutschland

 

Background:
Atrial tachycardia (AT) is commonly observed following orthotopic biatrial heart transplantation (O-BA-HTX). There remains some controversy regarding their clinical presentation, relationship with atrial anastomoses, and electrophysiologic characteristics. Novel radiofrequency-guided catheter ablation (RFCA) strategies combining electroanatomical activation mapping and myocardial substrate characterization have emerged. Data on the successful treatment of ATs in this specific patient cohort are limited. 

Objective:
The aim of this prospective study was to provide an easy electrophysiologic strategy for mapping and ablation of AT in patients post O-BA-HTX. It sought to assess the efficacy and safety of a novel, first-in-human approach for RFCA in this patient group. Additionally, the study aimed to evaluate long-term arrhythmia-free survival in these patients.

Methods:
A total of 35 consecutive O-BA-HTX patients who underwent RFCA for AT between 2017-2024 were included in this study. Data on procedural parameters, acute and long-term success und complications were analyzed. The primary endpoint was defined as recurrence of ATs longer than 30 seconds.

Results:
A total of 35 patients (mean age 57±16 years, 85% male) presented with therapy-refractory AT post O-BA-HTX. All patients underwent 3-demensional electroanatomic mapping and RFCA of their AT. Procedure time was 61.65±20.73 min; fluoroscopy time 2.74±1.66min; ablation time 9.35±2.78min. The electrophysiologic diagnoses were CTI-depended atrial flutter (AFL) in 62.9% (n = 22); RA-lateral line dependent AT (RA-LL) in 28.6% (n = 10); perimitral AFL in 5.7% (n = 2) and atrio-atrial (AA)-associated left atrial AT in 2.8% (n =1).  AA association was the responsible mechanism for AT in 31.43% (n=11, 10 in RA und 1 in LA), but the AA association was different in AA conduction (types of AA conduction: 1:1, 2:1 and variable AA conduction). A linear lesion incorporating CTI and a RA lateral line (L-Line, Figure 1) led to termination of atrial tachycardia in 91.5% (n = 32). All procedures were performed without any major complications. During a mean follow up of 18 months 1 patient developed AT-recurrence (n=1, 2.86%).No patient developed atrial fibrillation during follow-up.

Conclusion:
The novel L-Line approach offers a simple and effective ablation strategy that enhances long-term arrhythmia-free survival in patients following O-BA-HTX. This strategy offers promising results and could potentially standardize treatment protocols in this unique patient population. Further studies are needed to validate these initial observations.

Figure 1:
Flowchart for stepwise identification and ablation of AT post O-BA-HTX. Left, anatomical scheme. Right, Ablation lines depicted as a tree.

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