Checking Ablation Lines—Is Bidirectional Block Sufficient?

TL;DR

A patient with atrial flutter showed that confirming bidirectional block may not be enough to prevent arrhythmias, requiring additional mapping and ablation.

Contribution

Demonstrates that bidirectional block confirmation alone may miss slow conduction gaps, necessitating further arrhythmia induction and mapping.

Findings

Bidirectional block confirmation failed to detect a gap in the anterior mitral line.

Ablation at the identified slow conduction gap restored normal rhythm and prevented arrhythmia recurrence.

Abstract

This case report presents a 71-year-old man undergoing repeat ablation for atypical atrial flutter after prior pulmonary vein isolation and subsequent re-ablation involving an anterior mitral line and a posterior box. High-density mapping revealed reconnection at the left superior pulmonary vein, which was successfully re-isolated. Although bidirectional block of the anterior mitral line was confirmed via local activation time (LAT) mapping during differential pacing, burst stimulation induced atrial flutter. Further LAT mapping during flutter identified very slow conduction through a gap in the anterior mitral line. Ablation at this site restored sinus rhythm, and the arrhythmia was no longer inducible. This case highlights that bidirectional block confirmation alone may not suffice to detect gaps with slow conduction. It underscores the necessity of arrhythmia induction and mapping to reliably identify and address such gaps.

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