Catheter ablation related mitral valve injury: the importance of early recognition and rescue mitral valve repair.
BACKGROUND
An increasing number of catheter ablations involve the mitral annular region and valve apparatus, increasing the risk of catheter interaction with the mitral valve (MV) complex. We review our experience with catheter ablation-related MV injury resulting in severe mitral regurgitation (MR) to delineate mechanisms of injury and outcomes.


METHODS
We searched the Mayo Clinic MV surgical database over a 19-year period (1993-2012) and the electrophysiologic procedures database over a 23-year period (1990-2013) and identified 9 patients with catheter ablation related MV injury requiring clinical intervention.


RESULTS
Indications for ablation included atrial fibrillation (AF) [n = 4], ventricular tachycardia (VT) [n = 3], and left-sided accessory pathways [n = 2]. In all 4 AF patients, a circular mapping catheter entrapped in the MV apparatus was responsible for severe MR. In all 3 VT patients, radiofrequency energy delivery led to direct injury to the MV apparatus. In the 2 patients with accessory pathways, both mechanisms were involved (1 per patient). Six patients required surgical intervention (5 MV repair, 1 catheter removal). One patient developed severe functional MR upon successful endovascular catheter disentanglement that improved spontaneously. Two VT patients with persistent severe postablation MR were managed nonsurgically, 1 of whom died 3 months postprocedure.


CONCLUSIONS
Circular mapping catheter entrapment and ablation at the mitral annulus are the most common etiologies of MV injury during catheter ablation. Close surveillance of the MV is needed during such procedures and early surgical repair is important for successful salvage if significant injury occurs.
Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Christopher V
CV
Desimone
Mayo Clinic School of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Tiffany
T
Hu
Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.|Department of Internal Medicine, Division of Cardiovascular Diseases, Città della Salute e della Scienza, University of Turin, Turin, Italy.
Elisa
E
Ebrille
Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Faisal F
FF
Syed
Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Vaibhav R
VR
Vaidya
Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Yong-Mei
YM
Cha
Department of Cardiovascular Disease, Mayo Clinic Health System, Eau Claire, Wisconsin, USA.
Arturo M
AM
Valverde
Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Paul A
PA
Friedman
Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA.
Rakesh M
RM
Suri
Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.|Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Samuel J
SJ
Asirvatham
D000328:Adult; D000368:Aged; D017115:Catheter Ablation / Q000009:adverse effects*; D042241:Early Diagnosis; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000293:injuries* / Q000601:surgery; D008944:Mitral Valve Insufficiency / Q000175:diagnosis* / Q000209:etiology* / Q000601:surgery; D012189:Retrospective Studies; D055815:Young Adult
WPW syndrome; atrial fibrillation; catheter ablation; mitral valve damage; ventricular tachycardia