Ablation Of Typical Atrial Flutter Research Articles

A New Approach to Cavo-Tricuspidal Isthmus Ablation

cavo-tricuspidal isthmus (CTI) block assessment using right ventricular (RV) pacing in pts with ventriculo-atrial conduction. pts submitted to CTI ablation for typical atrial flutter were studied with a quadruple catheter in RV, a decapolar in the coronary sinus (CS), an eicosapolar around the tricuspidal annulus and an 8 mm ablator. Circumannular activation (CA) was analysed during CS and RV pacing in pts with spontaneous sinus rhythm or cardioverted during ablation. Pts without ventriculo-atrial conduction were excluded. The linear lesion was performed during RV pacing, looking at atrial signals splitting. CTI block was confirmed by analysis of CA during CS and RV pacing. out of 15, 9 (60%) pts were included. Before ablation, during RV stimulation, the collision front of CA shifted counter clockwise with respect to CS pacing, without variation of Halo-like catheter activation time (82±31 ms vs 77±26, p = 0.49). After ablation, CA was similar during CS and RV pacing, showing fully descending lateral right atrium activation (115±33 ms vs. 103±29, p = 0.09). Double potentials on the ablation line were more splitted during CS pacing than RV pacing (126±24 ms vs. 108±20 ms, p = 0.009), but less detached from the V wave. All pts were successfully ablated. in pts with ventriculo-atrial conduction, RV pacing can substitute CS pacing in the assessment of isthmus block.

Influence of Flutter Ablation Using Noncontact Mapping in Aneurismal Atrium on Exercise Capacity

The aim of this study was to assess whether ablation of typical atrial flutter in patients with right aneurismal dilated atrium and chronic heart failure affect quality of life and changes in clinical status defined by NYHA class, ejection fraction and changes in heart failure signs. In 11 consecutive patients (mean age 61 ± 13 years, 1 woman) with aneurismal atrium, moderate (NYHA class II-III) symptoms of heart failure, ejection fraction < 40% (28 ± 8%), LV end-diastolic diameter >60mm (66 ± 6mm) typical atrial flutter ablation was performed using noncontact mapping with the ensite 3000 System. All patients remained free of atrial flutter with an average follow-up for 12 month. Significant correlation was found by restoring sinus rhythm in aneurismal dilated atrium with NYHA class and exercise time. Favorable results with flutter ablation in aneurismal atrium were seen in terms of in increase in ventricular ejection fraction, increse in exercise tolerance, improve NYHA functional classification.

Carto System Reduced Chronic Recurrence Rate of Typical AFL Ablations

The recurrence rate after ablation of typical atrial flutter (AFL) is still higher than that of other supraventricular tachyarrhythmias. The purpose of the present study was to determine whether performing ablation using electro-anatomical mapping (CARTO) as guide is able to reduce the incidence of AFL recurrences during the follow-up. Our study population comprises two groups of patients with AFL who underwent linear ablation of cavo-tricuspidal isthmus: 1) from 1996 to 2002, the bidirectional block at level of isthmus was confirmed by conventional method such as changes of propagation sequence on the Halo catheter and/or occurrence of double potential on ablation line (Conv group); 2) from 2002 to 2005, the bidirectional block was confirmed by CARTO system (CARTO group). We enrolled 150 consecutive patients (age 63.0±11.9 yrs). The follow-up period averaged 921 days. The recurrence rate of AFL of Conv group was 12.4% (n=14/113) during 1189 days, while the recurrence rate of CARTO group was 8.1% (n=3/37) during 140 days. In patients who experienced recurrences, the isthmus length was longer than in patients who did not (30 vs 24 mm). The recurrence rate of AFL during the follow-up seems to be lower in patients in whom ablation was performed by means of CARTO system. An isthmus length greater than 30 mm is predictor of AFL recurrence.

Catheter inversion to achieve complete isthmus block in patients with typical atrial flutter

Endocardial catheter ablation is now considered as the therapy of first choice in highly symptomatic patients with recurrent atrial flutter. Despite of primary success rates between 90 and 100% complete isthmus block is sometimes hard to achieve. We present ablation results of 100 consecutive patients suffering from typical right atrial flutter. After a mean of 18 energy applications persistent bidirectional isthmus block could not be achieved in 16 patients and right atrial angiography was performed in all of them. In 9 patients a large Eustachian valve was detected and considered responsible for failure of endocardial catheter ablation of atrial flutter. Catheter manipulation targeting the anterior region of the Eustachian ridge was successful in all patients after looping the ablation catheter within the right atrium. With a mean of 3 additional RF applications, 6 of the 9 affected patients could be successfully ablated. Large Eustachian ridges are not a rare finding in patients undergoing ablation of typical right atrial flutter. Inversion of the ablation catheter within the right atrium is a simple technique providing excellent tissue contact of the ablation electrode with the anterior region of the Eustachian Ridge. Using this approach, the creation of bidirectional isthmus block is possible in the majority of the respective patients.

Pharmacological and ablative hybrid therapy of atrial fibrillation

The pharmacological and ablative hybrid therapy of atrial fibrillation (AF) consists of radiofrequency catheter ablation of antiarrhythmic drug-induced typical atrial flutter (AFl) and continuation of drug therapy. The purpose of this study was to determine the effect of this therapy on AF symptoms and quality of life (QoL). Forty-six patients were monitored after isthmus-ablation of drug-induced typical AFl and continuation of their antiarrhythmic drug treatment over a mean follow-up of 22.4+/-11.6 months. AF characteristics, symptoms and QoL before and after ablation were evaluated by the SF-36 question- naire, the Symptoms Checklist-Frequency and Severity Scale and the analysis of ECG recordings. 63% of patients demonstrated recurrences of AF. However, the frequency and duration of symptomatic episodes significantly decreased in 82.6 and 76% of patients. All categories of the SF-36 improved significantly and the AF symptomatology showed a relevant attenuation in 65.8% of the study population. The pharmacological and ablative hybrid therapy significantly reduced the mean number and the duration of symptomatic AF episodes as well as AF-correlated symptoms and was associated with significant QoL improvement.

Clinical Prediction of Cavotricuspid Isthmus Dependence in Patients Referred for Catheter Ablation of “Typical” Atrial Flutter

Typical atrial flutter (AFL) can be cured by catheter ablation of the cavotricuspid isthmus (CTI). The surface electrocardiogram (ECG) is not always diagnostic of isthmus dependence of AFL. The aim of this study was to evaluate clinical parameters for the prediction of isthmus-dependent AFL. Sixty consecutive adult patients without suspected atriotomy-related AFL, congenital heart disease, or previous AFL ablation, referred for catheter ablation of presumed typical AFL were studied. All patients had distinct flutter waves in the inferior leads, suggestive of CTI-dependent AFL, either on presentation to the electrophysiology (EP) lab or documented on prior ECG. Electrophysiology study was performed in the standard fashion. Patients who presented to the EP laboratory not in AFL underwent arrhythmia induction with a burst pacing protocol. A clinical history of persistent AFL (P = 0.0001) and existence of AFL on presentation to the EP laboratory (P = 0.0001) were strong predictors of CTI dependence. History of atrial fibrillation (P = 0.19), structural heart disease (P = 0.6), hypertension (P = 0.4), and previous cardiac surgery (P = 0.5), as well as the nature of AFL-related symptoms (P = 0.5), were not predictors of CTI-dependent AFL documented during EP study. In patients with ECG suggestive of typical AFL, the presence of persistent rather than paroxysmal AFL and presentation to the EP laboratory in AFL are strong predictors of CTI-dependent AFL. A paroxysmal pattern of AFL predicts noninducibility of CTI-dependent AFL during EP study. CTI ablation may therefore be less effective in these patients.

Methods to Determine Bidirectional Block of the Cavotricuspid Isthmus in Radiofrequency Ablation of Typical Atrial Flutter

Journal of Cardiovascular ElectrophysiologyVolume 16, Issue 7 p. 801-803 Methods to Determine Bidirectional Block of the Cavotricuspid Isthmus in Radiofrequency Ablation of Typical Atrial Flutter NADIR SAOUDI M.D., NADIR SAOUDI M.D. Centre Hospitalier Princesse Grace, MonacoSearch for more papers by this authorPHILIPPE RICARD M.D., PHILIPPE RICARD M.D. Centre Hospitalier Princesse Grace, MonacoSearch for more papers by this authorJEAN PAUL RINALDI M.D., JEAN PAUL RINALDI M.D. Centre Hospitalier Princesse Grace, MonacoSearch for more papers by this authorKHELIL YAÏCI M.D., KHELIL YAÏCI M.D. Centre Hospitalier Princesse Grace, MonacoSearch for more papers by this authorJEAN PHILIPPE DARMON M.D., JEAN PHILIPPE DARMON M.D. Centre Hospitalier Princesse Grace, MonacoSearch for more papers by this authorFREDERIC ANSELME M.D., FREDERIC ANSELME M.D. Centre Hospitalier Princesse Grace, MonacoSearch for more papers by this author NADIR SAOUDI M.D., NADIR SAOUDI M.D. Centre Hospitalier Princesse Grace, MonacoSearch for more papers by this authorPHILIPPE RICARD M.D., PHILIPPE RICARD M.D. Centre Hospitalier Princesse Grace, MonacoSearch for more papers by this authorJEAN PAUL RINALDI M.D., JEAN PAUL RINALDI M.D. Centre Hospitalier Princesse Grace, MonacoSearch for more papers by this authorKHELIL YAÏCI M.D., KHELIL YAÏCI M.D. Centre Hospitalier Princesse Grace, MonacoSearch for more papers by this authorJEAN PHILIPPE DARMON M.D., JEAN PHILIPPE DARMON M.D. Centre Hospitalier Princesse Grace, MonacoSearch for more papers by this authorFREDERIC ANSELME M.D., FREDERIC ANSELME M.D. Centre Hospitalier Princesse Grace, MonacoSearch for more papers by this author First published: 07 July 2005 https://doi.org/10.1111/j.1540-8167.2005.40624.xCitations: 27 Address for correspondence: Nadir Saoudi, M.D., Centre Hospitalier Princesse Grace, 98000 Monaco (Principauté). Fax: +377 97 98 97 32; E-mail: [email protected] J Cardiovasc Electrophysiol, Vol. 16, pp. 801-803, July 2005. Editor: Hugh Calkins, M.D. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume16, Issue7July 2005Pages 801-803 RelatedInformation

Pseudoblock and pseudoconduction across the cavotricuspid isthmus

Ablation of typical atrial flutter is dependent on creating a line of block in the inferior vena cava-tricuspid annulus isthmus (CTI), a critical part of the macroreentrant circuit. 1 Saoudi N. Atallah G. Kirkorian G. Touboul P. Catheter ablation of the atrial myocardium in human type I atrial flutter. Circulation. 1990; 81: 762-771 Crossref PubMed Google Scholar , 2 Cosio F.G. Lopez G.M. Goicolea A. Arribas F. Barrosa J.L. Radiofrequency ablation of the inferior vena cava-tricuspid valve isthmus in common atrial flutter. Am J Cardiol. 1993; 71: 705-709 Abstract Full Text PDF PubMed Scopus (511) Google Scholar Success of the linear lesion is confirmed by the presence of bidirectional block during pacing maneuvers from the low lateral right atrium and proximal coronary sinus (CS). 3 Poty H. Saoudi N. Nair M. Radiofrequency catheter ablation of atrial flutter: Further insights into the various types of isthmus block. Application to ablation during sinus rhythm. Circulation. 1996; 94: 3204-3213 Crossref PubMed Scopus (282) Google Scholar , 4 Cauchemez B. Haissaguerre M. Fischer B. Electrophysiological effects of catheter ablation of inferior vena cava-tricuspid annulus isthmus in common atrial flutter. Circulation. 1996; 93: 284-294 Crossref PubMed Scopus (307) Google Scholar The ability to accurately assess CTI block during CS pacing is dependent on at least two critical assumptions: (1) when pacing from the CS, the impulse does not propagate across the crista terminalis, and (2) clockwise activation of the CTI during CS pacing occurs via circumferential muscle fibers surrounding the CS rather than by superior transseptal propagation across Bachmann’s bundle.

319 Temporal pattern of conduction recurrence during radiofrequency ablation for typical atrial flutter

319 Temporal pattern of conduction recurrence during radiofrequency ablation for typical atrial flutter

319 Temporal pattern of conduction recurrence during radiofrequency ablation for typical atrial flutter

319 Temporal pattern of conduction recurrence during radiofrequency ablation for typical atrial flutter

“Pseudo”-AV block and right atrial electrical disconnection complicating ablation for typical atrial flutter

avoid ablation within the pulmonary veins, as well as near the esophagoatrial interface. Segmental ostial ablation guided by a 10-pole circular mapping catheter was then performed after circumferential ablation to ensure electrical isolation of each vein. There were no complications. At 6 months, the patient has remained free of AF as assessed by symptoms and periodic Holter monitoring. Conclusions: CT imaging used in conjunction with a non-fluoroscopic navigation system is a new and important tool for AF ablation. By providing a highly detailed anatomic representation of the left atrium, pulmonary veins and esophagus, CT imaging serves to verify the accuracy of NavX-generated geometry. Regions of interest, such as the pulmonary vein ostia, the left atrial roof, the esophago-atrial interface and the isthmus between the left atrial appendage and the left superior pulmonary vein, can be more accurately defined, potentially resulting in a more effective and precise ablation while avoiding serious complications, such as pulmonary vein stenosis and esophago-atrial fistulas.

Maintenance of cavo-tricuspidal isthmus conduction block after radiofrequency ablation

Inferior cavo-tricuspid isthmus (CTI) block is the success marker of typical atrial flutter (AFl) ablation (RFA). However, limited information is available on the long-term persistence of CTI block in patients (pts) with no clinical recurrences. The aim of our study was to assess the chronic efficacy of RFA of the CTI and to identify parameters associated with recurrences of conduction.

Determining inferior vena cava-tricuspid isthmus block after typical atrial flutter ablation

n typical atrial flutter, circular activation around the tricusid ring is possible because the terminal crest prevents hort-circuiting on the posterior wall, and the myocardium etween the inferior vena cava (IVC) and the lower rim of he tricuspid ring is the obligatory pathway to close the ircuit in the low right atrium (RA) (Figure 1). This IVC– ricuspid ring isthmus (cavotricuspid isthmus) has become he preferred target for ablation because it is the narrowest oint of the circuit, it is easily accessible, and it is located ar from the AV junction. Variations of the circuit all share he cavotricuspid isthmus as the obligatory path in the low A (Figure 1). Bidirectional block at the cavotricuspid isthmus has become he accepted endpoint of ablation during sinus rhythm.

Correlation of atrial electrocardiographic amplitude with radiofrequency energy required to ablate cavotricuspid isthmus-dependent atrial flutter

The purpose of this study was to evaluate a possible correlation between atrial ECG amplitude in common atrial flutter (AFL) and radiofrequency (RF) energy required to achieve cavotricuspid isthmus block. The amount of RF delivery required for ablation of typical AFL is variable. This variation has been attributed to the cavotricuspid isthmus anatomy. Atrial ECG amplitude can be a marker of atrial anatomic variations and therefore may correlate with RF duration required to achieve cavotricuspid isthmus block. Seventy consecutive patients were prospectively studied. Ablation of the cavotricuspid isthmus was performed by creating a line of block between the inferior tricuspid annulus and the inferior caval vein using 8-mm-tip electrode catheters. If more than 20 minutes of RF time was required to achieve conduction block, the catheter was changed to an irrigated-tip catheter. Atrial ECG amplitude was assessed in leads II, III, aVF, and aVL. A total of 14 +/- 11 minutes of RF energy was delivered to achieve block in all patients; 12 patients (8%) required more than 20 minutes. Atrial ECG amplitude showed highly significant correlations with cumulative RF energy (F and P waves in lead II: r = 0.703 and r = 0.737, P < .001). P-wave amplitude <0.2 mV and/or flutter wave amplitude <0.35 mV in lead II have a high negative predictive value to predict <20 min RF delivery (96% and 89% respectively). A significant correlation exists between atrial ECG amplitude and amount of RF required to ablate typical AFL. Atrial ECG amplitude may be a surrogate marker of characteristics of isthmus anatomy. These findings may influence the choice of catheter used for cavotricuspid isthmus ablation.

Mechanism of Propensity to Atrial Fibrillation in Patients Undergoing Isthmus Ablation for Typical Atrial Flutter

Mechanism of propensity to atrial fibrillation. Patients undergoing isthmus ablation for atrial flutter (AFL) may reveal postablation atrial fibrillation (AF). The electrophysiological mechanism is unclear. In patients with idiopathic AF, enhanced spatial dispersion of right atrial refractoriness was the substrate for the initiation of AF. We hypothesize that dispersion of right atrial refractoriness in patients undergoing AFL ablation is the major cause of postablation AF. Consecutive patients (n=42) undergoing isthmus ablation for typical AFL were included. Twelve right atrial unipolar electrograms were recorded. Inducibility of AF was assessed by a pacing protocol, starting with one extrastimulus, followed by more aggressive pacing until AF was induced. Mean fibrillatory intervals were used to assess local refractoriness of each recording site. Spatial dispersion of right atrial refractoriness was calculated as the coefficient of dispersion (CD-value: standard deviation of the mean of all local mean fibrillatory intervals as a percentage of the overall mean fibrillatory interval). A CD-value of 3.0 or less was defined as normal, whereas CD-value greater than 3.0 was considered enhanced dispersion. PES and refractoriness analysis were followed by isthmus ablation. Of the 42 patients, 29 had CD-value of 3.0 or less. In these 29 patients, AF was induced with 1 extrastimulus in only 1 patient, with 2 extrastimuli in 4 patients and burst pacing was required to induce AF in 24 of these 29 patients. Prior to the procedure, 5 of 29 patients had AF episodes, after ablation 6 of 29 patients. Of the 42 patients, 13 had CD-value greater than 3.0, AF was induced with a single extrastimulus in 11 patients, with 2 extrastimuli in the remaining 2 patients. Of the 13 patients, 11 had AF episodes both before and after ablation (P<0.001). Enhanced spatial dispersion of right atrial refractoriness may be the substrate for propensity to AF in patients with AFL. The substrate was associated with enhanced inducibility of atrial fibrillation.

Use of a New Non‐Fluoroscopic Three‐Dimensional Mapping System in Type I Atrial Flutter Ablation

We studied 40 patients who underwent cavo-tricuspid isthmus ablation for typical counterclockwise atrial flutter with cooled tip catheters between 2001 and 2003. Complete bi-directional isthmus block was created in all patients. A new, three-dimensional (3D), non-fluoroscopic mapping system was used in 20 patients (test group), and conventional fluoroscopy in 20 others (conventional group), using anatomic and electrophysiologic criteria in both groups. We measured the total procedure, ablation procedure, and overall fluoroscopy times, and the total number of radiofrequency (RF) applications delivered in the two groups. The overall fluoroscopy time was shorter in the test group (mean 8.8 minutes, range 2-17 minutes) than the conventional group (29.7 minutes, range 12-57 minutes; P < 0.001). Though the overall procedure time was similar in both groups (92.5 +/- 28.6 minutes vs 106.5 +/- 20.9 minutes; P = 0.067) the ablation duration (25.1 +/- 6.6 minutes versus 43.3 +/- 19.6 minutes; P = 0.0051) and the total RF applications (10.6 +/- 9.4 versus 16.4 +/- 9.4; P = 0.044) were smaller in the test group. The use of a new, 3D non-fluoroscopic mapping system markedly reduced the fluoroscopy exposure during typical atrial flutter ablation. It was also associated with a significant reduction in ablation time and in the number of RF applications. Since atrial flutter ablation is one of the most frequently performed procedures, this system may significantly reduce the overall amount of radiation exposure in high-volume laboratories.

Different Clinical Courses and Predictors of Atrial Fibrillation Occurrence After Transisthmic Ablation in Patients with Preablation Lone Atrial Flutter, Coexistent Atrial Fibrillation, and Drug Induced Atrial Flutter

The aim of this prospective study was to compare the long-term follow-up after transisthmic ablation of patients with preablation lone atrial flutter, coexistent AF, and drug induced atrial flutter to determine if postablation AF followed a different clinical course and displayed different predictors in these groups. The study evaluated 357 patients who underwent transisthmic ablation for typical atrial flutter. These were divided into four groups according to their preablation history. Group A included patients with typical atrial flutter and without preablation AF (n=120, 33.6%). Group B included patients with preablation AF and spontaneous atrial flutter (n=132, 37.0%). Group C patients had preablation AF and atrial flutter induced by treatment with IC drugs (propafenone or flecainide) (n=63, 17.6%) Group D included patients with preablation AF and atrial flutter induced by treatment with amiodarone (n=42, 11.8%). During a mean follow-up of 15.2 double dagger 10.6 months (range 6-55 months) AF occurred more frequently in groups B (56.1%) and C (57.1%) patients than in groups A (20.8%, P <0.0001) and D (31.0%, P <0.0001) patients. The results of multivariate analysis revealed that different clinical and echocardiographical variables were correlated with postablation AF occurrence in the different groups. Patients with atrial flutter induced by amiodarone have a significantly lower risk of postablation AF than patients with spontaneous atrial flutter and AF, and those with atrial flutter induced by IC drugs. Different clinical and echocardiographical variables predict postablation AF occurrence in different subgroups of patients.

Characteristics of virtual unipolar electrograms for detecting isthmus block during radiofrequency ablation of typical atrial flutter

Characteristics of virtual unipolar electrograms for detecting isthmus block during radiofrequency ablation of typical atrial flutter

Typical atrial flutter ablation outcome: correlation with isthmus anatomy using intracardiac echo 3D reconstruction.

To verify if sites of conduction gaps on the isthmus correlate with anatomical peculiarities using the intracardiac echo (ICE) and a new 3D device to reconstruct the isthmus in patients undergoing cavotricuspid isthmus ablation. Twenty patients underwent isthmus ablation using an 8 mm tip ablation catheter. Two-dimensional and 3D ICE reconstruction of the isthmus was made before, during and after ablation. At the end of the lesion line isthmus block was validated by electrophysiological criteria. In case of its absence we closed the remaining conduction gaps verifying the position of the sites with ICE. Fourteen patients required a median of 8 RF pulses to obtain complete isthmus block (Group A). In the remaining 6 patients isthmus block was obtained with a median of 25 RF pulses due to conduction gaps 'resistant' to ablation (Group B). Conduction gap positions assessed by ICE were located in the central portion of the isthmus below the coronary sinus os in 71% of cases in Group A and along a prominent Eustachian ridge in Group B patients, respectively. 3D reconstruction showed a smooth isthmus in Group A with a 'peak and valleys' isthmus in Group B. In these latter patients isthmus block was obtained only after the complete ablation of the prominent Eustachian ridge. The isthmus presents anatomical variants particularly due to Eustachian ridge peculiarities which may represent a site of conduction gaps "resistant" to ablation.

Results of catheter ablation of typical atrial flutter

The purpose of this study was to evaluate the safety and efficacy of radiofrequency (RF) ablation of typical atrial flutter by using an 8-mm electrode catheter and a 100-W RF power generator. A limitation of previous trials of catheter ablation of atrial flutter is that the data were not collected as part of a prospective multicenter clinical trial. The study results associated catheter ablation of typical atrial flutter in a cohort of 150 patients with an 88% acute efficacy rate. At 6-month follow-up, recurrent typical atrial flutter was observed in 13% of patients. Of the 12 patients with typical atrial flutter recurrence, 4 were symptomatic and 8 were asymptomatic. Procedure duration was a significant predictor of typical atrial flutter recurrence. The 12-month rate for development of atrial fibrillation was 30%. Catheter ablation of atrial flutter was associated with significant improvements in 5 of 8 domains of the Short Form 36 Survey (quality of life) and significant decreases in 13 of the 16 symptoms of the Symptom Checklist. The device- or procedure-related complication rate was 2.7%. Skin burns occurred at the dispersive pad site due to stronger RF power in 3 patients. Use of a dual dispersive pad system mitigated this problem. Thus, the results of this study associated catheter ablation of atrial flutter with high acute efficacy, a small risk of recurrent atrial flutter, and an important risk of atrial fibrillation during follow-up.