Wave speed guided point-by-point cavo-tricuspid isthmus ablation to reduce ablation and fluoroscopy in typical atrial flutter

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Background Ablation procedures for cavo-tricuspid isthmus (CTI) dependent typical atrial flutter (AFL) have traditionally been performed with conventional electrophysiology mapping guided by fluoroscopy. Three-dimensional electroanatomical mapping (EAM) systems have routinely been used to guide ablation of more complex arrhythmias, but in recent years, have been used for simple ablations with the aim of reducing irradiation. High voltage regions in the CTI have been described as a target in order to minimize procedure times, but there is a lack of knowledge regarding the utility of slow conduction zones for this purpose. Methods In a prospective cohort of patients undergoing 3D EAM assisted AFL ablation, we evaluated a novel strategy (NS) based on omnipolar vectors, using both wave speed and voltage information to focus radiofrequency (RF) lesions (see figure), and compared with a recent retrospective cohort of patients undergoing voltage-guided ablation (VG). Results A group of 26 consecutive patients with mean age 68±12 years and 88% male, underwent NS ablation, and were compared to 23 patients undergoing VG ablation, with no differences among patient characteristics. Of the 26 patients in group NS, 16 (53.9%) were successfully ablated targeting only 2 sites, representing the 2 most confluent areas of low wave speed and high voltage. A total of 24 (92.5%) were ablated successfully with targeting all sites of low wave speed. Only a single patient in the NS group required the completion of a classic CTI line. Average fluoroscopy time and radiation dose were lower in the NS group compared to VG group (1.1±2.4 min 19.5±41.7 mGray vs 8.2±10.2 min and 64.4±76.5 mGray, p=0.0014 and p=0.013, respectively). Furthermore, RF time trended towards reduction in the NS group. Conclusions A strategy based on targeting only areas of low wave speed is effective, limiting the need to complete a traditional CTI line, and reducing fluoroscopy in patients undergoin CTI ablation.