Ablation of perimitral flutter following catheter ablation of atrial fibrillation: Impact on outcomes from a randomized study (PROPOSE)

Rong Bai, Luigi Di Biase, Prasant Mohanty, Antonio Dello Russo, Michela Casella, Gemma Pelargonio, Sakis Themistoclakis, Sanghamitra Mohanty, Claude S. Elayi, Javier Sanchez, J. David Burkhardt, Rodney Horton, G. Joseph Gallinghouse, Shane M. Bailey, Aldo Bonso, Salwa Beheiry, Richard H. Hongo, Antonio Raviele, Claudio Tondo, Andrea Natale

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38 Scopus citations


MVI Block vs Trigger Ablation in PMFL. Introduction: Patients with previous ablation for atrial fibrillation (AF) may experience recurrence of perimitral flutter (PMFL). These arrhythmias are usually triggered from sources that may also induce AF. This study aims at determining whether ablation of triggers or completing mitral valve isthmus (MVI) block prevents more arrhythmia recurrences. Methods and Results: Sixty-five patients with recurrent PMFL after initial ablation of long standing persistent AF were included in this study. Thirty-two patients were randomized to MVI ablation only (Group 1) and 33 were randomized to cardioversion and repeat pulmonary vein (PV) isolation plus ablation of non-PV triggers (Group 2). MVI bidirectional block was achieved in all but 1 patient from Group 1. In Group 2, reconnection of 17 PVs was detected in 14 patients (42%). With isoproterenol challenge, 44 non-PV trigger sites were identified in 28 patients (85%, 1.57 sites per patient). At 18-month follow-up, 27 patients (84%) from Group 1 had recurrent atrial tachyarrhythmias, of whom 15 remained on antiarrhythmic drug (AAD); however, 28 patients from Group 2 (85%, P < 0.0001 vs Group 1) were free from arrhythmia off AAD. The ablation strategy used in Group 2 was associated with a lower risk of recurrence (hazard ratio = 0.10, 95% CI 0.04-0.28, P < 0.001) and an improved arrhythmia-free survival (log rank P < 0.0001). Conclusion: In patients presenting with PMFL after ablation for longstanding persistent AF, MVI block had limited impact on arrhythmia recurrence. On the other hand, elimination of all PV and non-PV triggers achieved higher freedom from atrial arrhythmias at follow-up.

Original languageEnglish (US)
Pages (from-to)137-144
Number of pages8
JournalJournal of cardiovascular electrophysiology
Issue number2
StatePublished - Feb 2012
Externally publishedYes


  • ablation
  • atrial fibrillation
  • atrial flutter
  • perimitral
  • pulmonary vein isolation

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)


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