LMI was performed by ablating from the left inferior PV to the posterolateral mitral annulus. LAAW ablation was performed by connecting the right superior pulmonary vein (PV) to the mitral annulus in two studies, left superior PV to the anterior mitral annulus in one study, and LA roof line to the mitral annulus in one study. In all studies, patients underwent pulmonary vein isolation (PVI), cavo-tricuspid isthmus ablation, and left atrial (LA) roof line ablation, following varied protocols. The remainder of patients had a mitral isthmus line drawn empirically. and 93% of patients in the study by Maheshwari et al. A mitral isthmus line was drawn for documented MAF in 25% of patients in the study by Heumer et al. Study characteristics are shown in Table Table2. Overall, 318 patients (54%) underwent LAAW ablation and 276 patients (46%) had LMI ablation. Patients were predominately male and many had failed anti-arrhythmic medications. Descriptive statistics are presented as means and standard deviations (SD) for continuous variables or number of cases ( n) and percentages (%) for dichotomous and categorical variables.īaseline demographics of patients included in the four studies are summarized in Table Table1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014. The statistical analysis was performed by the Review Manager (RevMan) Version 5.3. Funnel plot analysis was used to address publication bias. Random effects models for analyses were used with high heterogeneity (defined as I 2 > 25%) otherwise, fixed effects models of DerSimonian and Laird were used. Heterogeneity of effects was evaluated using the Higgins I-squared ( I 2) statistic. The Mantel-Haenszel methods are the fixed-effect methods used when event rates are low or study size is small, as the estimates of the standard errors of the effect estimates that are used in the inverse variance methods may be poor. Discrepancies were resolved by discussion or adjudication by a third author (J.C.H.).ĭata was summarized across treatment arms using the Mantel-Haenszel risk ratio (RR), inverse variance mean difference (MD). and O.M.A.) independently assessed the risk of bias of the included trials using standard criteria defined in the Cochrane Handbook for Systematic Reviews of Interventions. and O.M.A.) independently assessed the quality items and discrepancies were resolved by consensus or involvement of a third reviewer (J.C.H), if necessary. Disagreements were resolved by consensus. Information was gathered using standardized protocol and reporting forms. Outcomes were extracted from original manuscripts and supplementary data. and O.M.A.) independently performed literature search and extracted data from eligible studies. We aimed to compare the efficacy and safety between LAAW and LMI lines. The studies had to fulfill the following criteria to be considered in the analysis: (1) Studies had to have compared outcomes in patients who underwent ablation with LAAW versus LMI lesion sets (2) Studies had to have compared and reported rates of achieving bidirectional block, ablation times, ablation line length, LAA activation delay, rates of pericardial effusions, and/or maintenance of sinus rhythm (3) Studies must have been published in a peer-reviewed scientific journal. The PRISMA statement for reporting systemic reviews and meta-analyses was applied to the methods for this study. Studies were selected by two independent reviewers. Search terms included ( Mitral Annular Flutter OR Atrial Fibrillation) and ( Mitral Isthmus Ablation or Anterior Mitral Ablation) and ( Catheter Ablation). The reference list of all eligible studies was also reviewed. We searched PubMed,, Medline, Google Scholar, and the Cochrane Central Register of Clinical Trials (Cochrane Library, Issue 09, 2017). The purpose of our current study was to perform a systematic review of the literature and meta-analysis to compare the efficacy and safety of both approaches. Both approaches have been shown to be effective, but the LMI line often requires additional coronary sinus (CS) ablation to achieve bidirectional block. While the LAAW line is drawn between the anterior mitral isthmus and right superior pulmonary vein (or occasionally the left superior pulmonary vein or roof line), the LMI line is drawn between the left lower pulmonary vein and LMI. The two most common approaches for ablation of peri-mitral flutter include a left atrial anterior wall (LAAW) line and a lateral mitral isthmus (LMI) line. MAF is often resistant to both rate-controlling and antiarrhythmic drugs, thus necessitating catheter ablation for treatment. Mitral annular flutter (MAF) is the most common left atrial macro-reentrant atrial arrhythmia following catheter ablation of atrial fibrillation (AF).
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