Atrial Flutter Patients Research Articles

Abstract TP138: Chronic Kidney Disease in Heart Failure Patients is Associated with Increased Prevalence of Atrial Fibrillation or Atrial Flutter as well as CVA/TIA

Background: The CHADS-VASC score does not incorporate renal dysfunction in stroke risk assessment in patients with atrial fibrillation and the prevalence of atrial fibrillation, atrial flutter, and cerebrovascular accidents (CVA) in patients with concurrent CHF and CKD is not well investigated. Objective: Evaluate the prevalence of history of stroke, atrial fibrillation, atrial flutter in patients with CHF and CKD. Methods: Data from the single institution Get With The Guidelines- Heart Failure (GWG-HF) cohort of 2938 consecutive inpatients with known GFR was utilized. CHADS-VASC score was calculated from the GWG-HF variables. Chronic kidney disease (CKD) was defined as GFR <60 ml/min. Results: An overwhelming majority (95%) of GWG-HF patients had elevated >1 CHADS-VASC score, which was also significantly more common in patients with CKD (97.6% vs. 91.7% in patients without CKD, p<0.0001). Average CHADS-VASC score was also significantly increased in patients with CKD (4+/-1.3 vs. 3.3+/-1.4, p<0.0001). Furthermore, CKD was associated with increased prevalence of atrial fibrillation and/or flutter (45.6% vs. 35.3%, p<0.0001) and stroke history (17.5% vs. 12.3%, p=0.002). When stroke and TIA histories were removed from the CHADS-VASC score ("CHAD-VASC score"), the remaining variables were strongly predictive of stroke or TIA (14.2% vs. 3.8%, p<0.0001). In multivariate logistic regression analysis, both CHAD-VASC score (OR 2.6, 95%CI 1.3-5.4, p=0.009) and CKD (OR 1.5, 95%CI 1.2-1.8, p=0.001) were associated significantly increased odds of prior stroke or TIA. Conclusions: In patients admitted with heart failure, CKD is associated with increased prevalence of atrial fibrillation or atrial flutter as well as increased prevalence of CVA/TIA. Further prospective studies are warranted to examine whether CKD history should be included in stroke risk assessment in patients with atrial fibrillation or atrial flutter, in conjunction with existing risk assessment frameworks.

Ablation of a new onset atypical atrial flutter in patient early after cardiac surgery.

Ablation of a new onset atypical atrial flutter in patient early after cardiac surgery.

96 Appropriate Stroke Prophylaxis Action After US Emergency Department Diagnosis and Discharge of Atrial Fibrillation and Flutter Patients

Oral anticoagulation (OAC) reduces stroke and mortality risk in patients with nonvalvular atrial fibrillation and flutter (AFF). The incidence of US emergency department (ED) OAC initiation is poorly understood, as are the appropriate actions following discharge. We examined stroke prophylaxis actions on, and shortly following, ED discharge of stroke-prone AFF patients in a large integrated health care delivery system. We included all adults with a primary diagnosis of nonvalvular AFF, high stroke risk (CHA2DS2-VASc ≥2), and no recent (<90d) OAC at discharge from 21 EDs in Kaiser Permanente Northern California between 2010-2017. Rates of appropriate stroke prevention action were calculated for all eligible discharges per calendar year. Actions were defined as either (1) an OAC prescription by an ED or follow-up provider, (2) a referral to a pharmacy-led anticoagulation management service (AMS), or (3) receipt of both an OAC prescription and AMS referral, within 10 days of ED discharge. We estimated appropriate OAC action (yes/no) with a mixed logistic model with sex, age, race, Hispanic ethnicity, stroke (CHA2DS2-VASc) and bleeding (HAS-BLED) risk and year as a fixed effect, and accounting for clustering by patient. Among 10,281 eligible ED discharges, mean age was 73.7 (STD 11.4) years, 61% were female, and mean CHA2DS2-VASc score was 3.7 (STD 1.62). From 2010 to 2017, there was steady increase in patients receiving both an OAC prescription and referral to AMS, 16.0 to 27.9% (Figure). The rate of no intervention decreased from 82.4 to 65.0% of eligible patients. Factors inversely associated with stroke prevention action within 10 days of ED discharge include female sex (aOR 0.79, 95% CI 0.71-0.88), age >74 years (0.59, 0.45-0.76) vs <64yo, high bleeding risk by HAS-BLED score (0.70, 0.58-0.85) vs low risk respectively, and highest stroke risk (CHA2DS2-VASc score 6-9) (0.70, 0.60-0.84) vs lower risk (CHA2DS2-VASc scores 2-4). The odds of receiving any action was 2.6 times higher in 2017 compared to 2010 (aOR 2.60, 2.08-3.24). Within a community-based ED population of AFF patients at high-stroke risk, the rate of appropriate stroke prevention action increased over the 7-year study period. However, there remains an opportunity to improve AFF thromboprophylaxis as more than half of the eligible patients in 2017 were not receiving appropriate stroke prevention action within 10 days of their index visit. Additionally, female sex and those greater than 74yo were less likely to receive appropriate action compared to men and those younger than 65yo. The undertreatment of those greater than 74yo suggests a misunderstanding of the net clinical benefit associated with OAC in the elderly. Furthermore, opportunities to address sex disparities exist as we seek to improve stroke prophylaxis in nonvalvular AF patients discharged from the ED.

1203Typical atrial flutter is a manifestation of previously silent coronary artery disease

Abstract Background Long-term mortality after ablation of typical atrial flutter has been found to be increased two fold in comparison to atrial fibrillation ablations through a period of five years with unclear mechanism. Methods We analysed 189 consecutive patients who underwent ablation for typical atrial flutter (AFL), in which the incidence of atrial flutter was the first manifestation of cardiac disease. According to clinical standards of our center, the routine recommendation was to evaluate for CAD by invasive angiogram or CT-scan. We compared the AFL patients to 141 patients with paroxysmal atrial fibrillation (AFIB) without known structural heart disease who underwent ablation in the same period and who had routine coronary angiograms performed. Results Out of 189 patients who presented with AFL, coronary status was available in 152 patients (80.4%). Both groups were balanced for mean age (64.9 years in AFL vs. 63.2 years in AFIB; p=0.15), body-mass-index (BMI; 28.8 vs. 28.5 kg/m2; p=0.15), CHA2DS2-VASc-Score (2.20 vs. 2.04; p=0.35), smoking status (22.2% smokers vs. 28.4%; p=0.23) and renal function (GFR &gt;60 ml/min in 96.7% of all patients vs. 95.7%; p=0.76). There were significantly lower values for left-ventricular ejection fraction (52.5% vs. 59.7%; p&lt;0.001), female sex (17.0% vs. 47.5%; p&lt;0.001), hyperlipidemia (37.9% vs. 58.9%; p&lt;0.001) and family history of cardiovascular disease (15.0 vs. 31.9%; p=0.001) in the AFL vs. AFIB cohorts. CAD with stenoses &gt;50% was found in 26.3% of all patients with available coronary status in AFL and in 7.0% in AFIB (p&lt;0.001). CAD with stenoses &gt;75% in 16.4% in AFL whereas only in 1.4% in AFIB (p&lt;0.001). Multivessel disease was detected in 10.5% in AFL and 0.7% in AFIB (p&lt;0.001). After correction for age, LVEF, BMI, CHA2DS2-VASc-Score and it's individual components, smoking status, hyperlipidemia and family history of cardiovascular disease, there was a more than five-fold increase in the likelihood of CAD with stenosis &gt;50% in AFL as compared to AFIB (OR 5.26). A multivariate analysis was performed in the AFL group. Patients with clinically relevant stenoses (&gt;75%) were older (70.6 years vs. 63.8 years; p=0.001), had a higher number of risk factors (3.08 vs. 2.24; p≤0.0016) and a higher CHA2DS2-VASc-Score (3.20 vs 2.00; p&lt;0.0001). With logistic regression, significant CAD could be predicted by higher values for CHA2DS2-VASc-Score with an exponential rise to a pretest-probability of 42.1% at a value of 4 points. Odds ratios of CAD with AFL vs AFIB Discussion This data suggests that typical atrial flutter constitutes a manifestation for previously asymptomatic CAD. Due to the inclusion criteria, CAD has to be considered silent and stable in most of the patients. Therefore, the presence of typical atrial flutter in formerly healthy patients should raise suspicion of otherwise silent CAD and initiate further investigations and risk-stratification with particular emphasis on the individual CHA2DS2-VASc-Scores.

Association between serum potassium levels and short-term mortality in patients with atrial fibrillation or flutter co-treated with diuretics and rate- or rhythm-controlling drugs.

We investigated the association between potassium levels and 90-day all-cause mortality in atrial fibrillation or flutter (AF) patients co-treated with diuretics and rate- or rhythm-controlling drugs. During 2000-12, first-time AF patients treated with beta-blockers, amiodarone, sotalol, verapamil, or digoxin combined with any diuretic within 90 days post-AF discharge were included. Following co-treatment, a potassium measurement within 90 days after initiating diuretic treatment was required. Mortality risk associated with potassium <3.5, 3.5-3.7, 3.8-4.0, 4.5-4.7, 4.8-5.0, and >5.0 mmol/L (reference: 4.1-4.4 mmol/L) was assessed using multivariable Cox regression. In total, 14425 AF patients were included (median age: 78 years; women: 52%). Patients most often received beta-blocker monotherapy (29%), beta-blockers and digoxin combined (25%), digoxin monotherapy (24%), amiodarone monotherapy (3%), and verapamil monotherapy (3%). Increased 90-day mortality risk was associated with <3.5 mmol/L [hazard ratio (HR) 2.05, 95% confidence interval (CI) 1.68-2.50], 3.5-3.7 mmol/L (HR 1.28, 95% CI 1.05-1.57), 4.5-4.7 mmol/L (HR 1.20, 95% CI 1.02-1.41), 4.8-5.0 mmol/L (HR 1.37, 95% CI 1.14-1.66), and >5.0 mmol/L: (HR 1.84, 95% CI 1.53-2.21). Compared with beta-blocker monotherapy, rate- or rhythm-controlling drugs did not modify the association between potassium groups and mortality risk. In addition to hypo- and hyperkalaemia, low and high normal range potassium levels were associated with increased 90-day mortality risk in AF patients co-treated with diuretics and rate- or rhythm-controlling drugs. These associations were independent of rate- or rhythm-controlling drugs.

A prospective observational survey on landiolol in atrial fibrillation/atrial flutter patients with chronic heart failure – AF-CHF landiolol survey

BackgroundAtrial fibrillation and atrial flutter occur commonly in patients with heart failure. Ultrashort-acting β-blockers, including landiolol, can rapidly control heart rate. As part of postmarketing surveillance for landiolol in Japan, a real-world drug-use survey (AF-CHF landiolol survey) was established for the treatment of atrial fibrillation and atrial flutter in patients with heart failure. We report the safety and effectiveness of landiolol from this survey, focusing on adverse events/adverse drug reactions. MethodsConsecutive patients with cardiac dysfunction who received landiolol (continuous intravenous infusion, starting at 1μg/kg/min) for atrial fibrillation or atrial flutter in routine clinical practice in Japan were enrolled between June 2014 and May 2016. Safety variables included adverse events and adverse drug reactions (number of patients and events, incidence rate, types, seriousness). Effectiveness variables included the proportion of patients with a ≥20% decrease in heart rate. ResultsData were available for 1121 patients (safety analysis set); 888 patients were evaluable for effectiveness parameters. Mean (± standard deviation) patient age was 72.5±13.5 years, 57.2% were male. Most patients (84.2%) received landiolol for atrial fibrillation. Overall, 174 adverse events occurred in 140 patients (12.5%), including 105 serious adverse events. The most common type of adverse events was cardiac (60 events). Seventy-five events in 63 patients were categorized as adverse drug reactions (5.6% of patients). Mean heart rate decreased substantially after treatment with landiolol, by ≥20% in 77.5% of patients. ConclusionsIn a real-world setting in Japan, landiolol for the treatment of atrial fibrillation or atrial flutter with heart failure was acceptable without new safety concerns, and most patients achieved effective heart rate control during their arrhythmias.

Prevalence of extra-appendage thrombosis in non-valvular atrial fibrillation and atrial flutter in patients undergoing cardioversion: a large transoesophageal echo study.

The aim of our study was to evaluate the prevalence of left atrial cavity and appendage thrombosis in patients undergoing cardioversion for non-valvular atrial tachyarrhythmias. In persistent atrial tachyarrhythmias, 90% of thromboses are reported to be located inside the left atrial appendage. This prevalence refers to old studies and meta-analysis in a mixed population of valvular and non-valvular atrial fibrillation. Left atrial cavity thrombosis in non-valvular atrial fibrillation has not been investigated recently in large-scale studies. A total of 1,420 consecutive adult patients with paroxysmal or persistent atrial tachyarrhythmias, candidates to cardioversion, who opted for a transoesophageal echocardiography-guided strategy, were enrolled in the study. Mitral stenosis, rheumatic valve disease and mechanical prostheses were excluded. In total there were 91 thrombi in 87 patients with a prevalence of 6.13% (87/1,420). Patients with left atrial thrombosis had predisposing clinical and echo characteristics (heart failure, lower ventricular function and higher atrial volume). Except for one case in which the thrombus was located in the left atrial cavity (0.07%), and three in the right appendage, all thromboses were detected in the left atrial appendage. Extra-appendage thrombosis is a very rare finding in non-valvular persistent and paroxysmal atrial tachyarrhythmias and, when present, a left appendage thrombus is usually concomitant.

Anatomy of the cavotricuspid isthmus for radiofrequency ablation in typical atrial flutter

Radiofrequency (RF) catheter ablation is one of the most common strategies for the current management of cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL). The interindividual anatomic variability can influence the duration and outcome of ablation procedure. The purpose of this study was to establish complication rates in patients undergoing RF catheter ablation for CTI-dependent AFL, assess the role of CTI morphology in procedural success, and determine the anatomic variability of CTI exvivo. RF catheter ablation for CTI-dependent AFL was performed in 337 consecutive patients. Angiographically determined CTI morphology was classified as either simple or complex due to pouchlike recesses. Macroscopic and histologic examination of the CTI was performed in 104 heart specimens from consecutive autopsies. Complex CTI anatomy was present in 10.9% of AFL patients. RF application time to achieve bidirectional isthmus block was longer in patients showing pouchlike recesses than in those without (10.7 vs 8.3 min; P= .025). Acute procedure failure or major complications occurred in 3 cases, all with complex CTI anatomy. A pouchlike recess of the CTI was present in 9.6% of autopsy hearts. Histomorphometric analysis of the CTI atrial wall demonstrated that the central level was the thinnest in the 3 sectors and the paraseptal level was the thickest. Although RF catheter ablation is a safe and effective procedure for AFL treatment, CTI anatomic complexity can affect ablation parameters and outcome. Standard definition of CTI morphologic variants is recommended. Preprocedural assessment of CTI anatomy might lead to personalized ablation preventing potential difficulties and complications.

Comparison of incidence of acute kidney injury, chronic kidney disease and end-stage renal disease between atrial fibrillation and atrial flutter: real-world evidences from a propensity score-matched national cohort analysis.

We investigated the adverse renal outcomes in patients affected by either atrial fibrillation (Afib) or atrial flutter (AFL). Using the Taiwan National Health Insurance research database, both cohorts were 1:1 propensity score matched based on age, sex, index year, and comorbidity using logistic regression model. Hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) of acute kidney injury (AKI), chronic kidney disease (CKD), and end-stage renal disease (ESRD) between the two cohorts were obtained using Cox proportional hazard regression models. Competing-risks regression models were applied to calculate the subhazard ratios (SHRs) and corresponding 95% CIs of the adverse renal outcomes. Afib patients were 1.15 and 1.33 times more likely to experience CKD and ESRD, respectively, than AFL patients (incidence rate per 10,000 person-years (IR): CKD, 10.8 vs 9.41; ESRD, 4.44 vs 3.34), with the adjusted HRs of 1.18 and 1.32 (CKD, 95% CI = 1.07-1.30; ESRD, 95% CI = 1.12-1.55). Afib patients were 1.08 times (95% CI = 1.01-1.16) more likely to have AKI than AFL patients after adjusting for confounding covariates. Competing risk analysis showed that Afib patients were 1.08 (95% CI = 1.01-1.15), 1.18 (95% CI = 1.07-1.30) and 1.32 (95% CI = 1.12-1.55) times more likely to experience AKI, CKD and ESRD than AFL subjects. This study showed that Afib conferred worse renal events of AKI, CKD and ESRD than AFL.

Radiofrequency ablation of the cavotricuspid isthmus for management of atrial flutter in patients with congenital heart disease after tricuspid valve surgery: A single-center experience

Typical atrial flutter involving the cavotricuspid isthmus (CTI) is the most common reentrant arrhythmia in congenital heart disease and ablation is effective in its management. However, congenital heart disease patients often require surgical interventions on their tricuspid valve that utilize prosthetic material, making CTI ablation technically challenging. To describe the techniques and outcomes of CTI ablation in the presence of prior tricuspid valve repair or replacement. We included all patients who had undergone tricuspid valve repair utilizing an annuloplasty ring or tricuspid valve replacement who underwent CTI ablation for treatment of atrial arrhythmias between 2005 and 2017. Acute procedural success was defined as demonstration of bidirectional conduction block across the CTI. Long-term success was defined as lack of arrhythmia recurrence on monitoring or related symptoms. Sixteen patients met the inclusion criteria. Twelve (75%) patients had Ebstein's anomaly, 14 (88%) patients had a prosthetic tricuspid valve, and 2 (12%) patients had annuloplasty ring. Acute success was achieved in all cases, with no complications. Radiofrequency ablation was required on the ventricular side in 9 (56%) patients. In 1 case, ablation in the small cardiac vein was required. All patients remained free from atrial flutter during 18 months follow-up (range, 1-101 months). Our study demonstrates the safety and efficacy of catheter ablation of the CTI in the presence of a tricuspid annuloplasty ring or a prosthetic tricuspid valve. This may require ablation from the ventricular side of the valve to target atrial tissue rendered inaccessible as a result of tricuspid valve surgery.

Active management of atrial fibrillation or flutter in emergency department patients with renal impairment is associated with a higher risk of adverse events and treatment failure.

Atrial fibrillation or flutter (AFF) patients with renal impairment have poor long-term prognosis, but their emergency department (ED) management has not been described. We investigated the association of renal impairment upon outcomes after rate or rhythm control (RRC) including ED-based adverse events (AE) and treatment failure. This cohort study used an electrocardiogram database from two urban centres to identify consecutive AFF patients and reviewed charts to obtain comorbidities, ED management, including RRC, prespecified AE, and treatment failure. Patients were dichotomized into a normal estimated glomerular filtration rate (eGFR) &gt; 60 mL/min/1.73 m2) or impaired renal function ("low eGFR"). Primary and secondary outcomes were prespecified AEs and treatment failure, respectively. We calculated 1) adjusted excess AE risk for patients with decreased renal function receiving RRC; and 2) adjusted odds ratio of RRC treatment failure. Of 1,112 consecutive ED AFF patients, 412 (37.0%) had a low eGFR. Crude AE rates for RRC were 27/238 (11.3%) for patients with normal renal function and 26/103 (25.2%) for patients with low eGFR. For patients with low eGFR receiving RRC, adjusted excess AE risk was 13.7%. (95% CI 1.7 to 25.1%). For patients with low eGFR, adjusted odds ratio for RRC failure was 3.07. (95% CI 1.74 to 5.43) CONCLUSIONS: In this cohort of ED AFF patients receiving RRC, those with low eGFR had significantly increased adjusted excess risk of AE compared with patients with normal renal function. Odds of treatment failure were also significantly increased.

Phase singularity point tracking for the identification of typical and atypical flutter patients: A clinical-computational study

Atrial Flutter (AFL) termination by ablating the path responsible for the arrhythmia maintenance is an extended practice. However, the difficulty associated with the identification of the circuit in the case of atypical AFL motivates the development of diagnostic techniques. We propose body surface phase map analysis as a noninvasive tool to identify AFL circuits.Sixty seven lead body surface recordings were acquired in 9 patients during AFL (i.e. 3 typical, 6 atypical). Computed body surface phase maps from simulations of 5 reentrant behaviors in a realistic atrial structure were also used. Surface representation of the macro-reentrant activity was analyzed by tracking the singularity points (SPs) in surface phase maps obtained from band-pass filtered body surface potential maps.Spatial distribution of SPs showed significant differences between typical and atypical AFL. Whereas for typical AFL patients 70.78 ± 16.17% of the maps presented two SPs simultaneously in the areas defined around the midaxialliary lines, this condition was only satisfied in 5.15 ± 10.99% (p < 0.05) maps corresponding to atypical AFL patients. Simulations confirmed these results.Surface phase maps highlights the reentrant mechanism maintaining the arrhythmia and appear as a promising tool for the noninvasive characterization of the circuit maintaining AFL. The potential of the technique as a diagnosis tool needs to be evaluated in larger populations and, if it is confirmed, may help in planning ablation procedures.

Is proximal coronary sinus involved in the circuit in some cases of ECG "typical" atrial flutter?

It is commonly conceived that coronary sinus (CS) participates in atrial flutter (AFL) circuit but limited to the fibers surrounding its ostium. We evaluated the involvement of proximal CS in typical AFL. Twenty AFL patients underwent entrainment mapping using postpacing interval minus AFL cycle length (PPI-AFL CL) including CS where a decapolar catheter was positioned with proximal bipole 1 cm from the ostium. We compared patients with proximal CS within the circuit (group 1, PPI-AFL CL ≤ 20 ms + concealed entrainment) and those without (group 2, PPI-AFL CL > 20 ms). Group 1 patients were older, 77.5 ± 4 vs 71 ± 12 years (P < 0.05). No difference was found in AFL CL, PPI-AFL CL at cavotricuspid isthmus (CTI) entry, plateau, and septal site. Group 1 patients had shorter PPI-AFL CL at proximal CS (9 ± 3 vs 40 ± 15 ms; P < 0.001) and fragmented mesodiastolic CS atrial potentials (APs) (106 ± 27 vs 58.5 ± 22 ms; P < 0.001). A mid-septal unexcitable scar was found in five of eight group 1 patients vs one of 12 group 2 patients (P < 0.05). All were ablated at CTI. A patient had AFL recurrence and underwent a second attempt: PPI-AFL CL was 60 ms at CTI entry and less than or equal to 20 ms at septal CTI and proximal CS; AFL was terminated 1 cm inside CS, applying RF at a fragmented AP. Proximal CS appears to be involved in a substantial subset of typical AFL patients, in whom advanced age, fragmented CS APs, and the presence of right atrial scar are prevalent. Proximal CS might be considered as an un-"innocent by-stander," but able, in rare cases, to generate a second AFL circuit.

High-Detailed evaluation of the right atrial anatomy by three-dimensional rotational angiography during ablation procedures for atrioventricular nodal reentrant tachycardia and atrial flutter

Aim. 3D Rotational angiography (3DRA) allows for detailed reconstruction of atrial anatomy and is often used to facilitate pulmonary vein isolation. This study aimed to reappraise the anatomy of the right atrium (RA) using 3DRA, specifically looking at Koch’s triangle and the cavotricuspid isthmus (CTI) in atrio-ventricular reentrant tachycardia (AVNRT) and atrial flutter (AFl) ablation. Methods and results. 3DRA was performed in 97 patients: AVNRT = 51 and AFl = 46. Dimensions of Koch’s triangle and CTI were highly variable between individuals but were not different in both ablation groups. RA volume was significantly larger in AFl patients (p = .004) while indexed RA volume to the body surface area (RAVI) was lightly different (p = .024). In univariate Cox analysis, age (p = .003), RAVI (p < .001) and previous ablation of AFl (p = .003) were predictors of AF occurrence . In multivariate Cox analysis, RAVI was the only independent predictor of AF occurrence. RAVI >80 ml/m2 was a strong predictor for AF during follow-up. Conclusion. 3DRA allows for detailed per-procedural evaluation of RA anatomy and revealed a great variability in Koch’s triangle and CTI dimensions and morphology. RA enlargement as measured by RAVI was an independent predictor for AF occurrence during follow-up.

Prophylactic Atrial Fibrillation Ablation in Atrial Flutter Patients without Atrial Fibrillation: A Meta-Analysis with Trial Sequential Analysis.

BackgroundNew-onset atrial fibrillation (AF) is common after atrial flutter (AFL) ablation, but it was unclear whether AF ablation could reduce the incidence of AF in AFL patients without AF history. The present meta-analysis was conducted to evaluate the benefit of prophylactic AF ablation in reducing the occurrence of AF in typical AFL patients.Material/MethodsWe systematically searched PubMed, EMBASE, and the Cochrane Library from inception to December 2017 for randomized controlled trials (RCTs) that assessed the efficacy of AF ablation in reducing the occurrence of AF in AFL patients without AF. Trial sequential analysis (TSA) was used to control random errors and calculate the required information size.ResultsFour trials (n=357 patients) met the inclusion criteria and were included in our meta-analysis. The incidence of AF after AFL ablation was 46.4%. We observed that prophylactic AF ablation reduced the AF incidence compared with simple AFL ablation (26.1% versus 46.4%, RR: 0.57, 95% CIs: 0.42–0.76, P=0.0002) with a prolonged procedure duration (P<0.00001) and fluoroscopy time (P=0.004). Further TSA indicated that more RCTs were needed to reach more conclusive results. There was no significant difference in clinical complications (P=0.33) between the 2 groups.ConclusionsThis meta-analysis provides evidence that prophylactic AF ablation may be more effective than simple AFL ablation in reducing AF incidence after AFL ablation. Large prospective RCTs are warranted to confirm the benefit of prophylactic AF ablation in AFL patients without AF history.

A Comparison of the Efficacy of Voltage-directed Cavotricuspid Isthmus Ablation Using Mini Versus Conventional Electrodes

Cavotricuspid isthmus (CTI) ablation is a current first-line management method for typical atrial flutter. A voltage-directed technique that systematically targets points of maximal voltage has be found to reduce procedure and fluoroscopy times without increasing recurrence. We hypothesized that this technique’s efficiency would be enhanced by using signals from radial minielectrodes of a novel catheter (IntellaTip MiFi™; Boston Scientific, Natick, MA, USA). Prospectively, atrial flutter patients underwent voltage-directed ablation with a nonirrigated 8-mm-tip catheter. Ablation was either directed by conventional bipolar electrodes (group A, n = 13) or mini-electrodes (group B, n = 17) with the goal of achieving bidirectional block at the CTI and a subsequent observation time of 30 minutes. Total radiofrequency application time and lesion numbers were not significantly different. Group B had a lower mean power [38.7 watts (W) ± 2.0 W versus 44.8 W ± 1.9 W; p < 0.05] and a tendency for longer fluoroscopy and procedure times. In three of the cases in group B, a switch to an irrigated catheter was required in order to achieve bidirectional block. In group A, bidirectional block was obtained in all patients using the nonirrigated catheter with no significant increase in reconnection. Differences in the catheter performance between the two groups were driven by poorer performance of the MiFi™ catheter (Boston Scientific, Natick, MA, USA) in patients presenting in atrial flutter. Electroanatomical mapping revealed a more proximal localization of the maximal voltage by the minielectrodes as compared with the conventional bipolar electrodes, resulting in less efficient identification and ablation of the conducting muscle bundles. Final results indicated CTI ablation using minielectrodes is not superior to conventional bipolar electrodes in the use of 8-mm, nonirrigated electrodes.

Frequency of atrial arrhythmias after atrial flutter ablation and the effect of presenting rhythm on the day of ablation

ABSTRACTRadiofrequency catheter ablation of the cavotricuspid isthmus is a proven therapy for typical atrial flutter (AFl); however, in some patients, new atrial arrhythmias (AA) may occur after AFl ablation. This study explored the difference in the occurrence of spontaneous AA after AFl ablation as a function of the patient's presenting rhythm on the day of the AFl ablation. A retrospective study of consecutive patients who underwent AFl ablation at Baylor University Medical Center at Dallas was performed. A total of 188 subjects were included; 50% (94) presented in AFl (Group AFl) on the day of the ablation procedure and 94 presented in sinus rhythm (SR; Group SR). Group AFl patients were older (P < 0.001), more likely to have diabetes (P = 0.03), and more likely to have undergone previous heart surgery (P = 0.03). The median size of the left atrium was 4 cm (range 2.8–6.8) in Group AFl compared with 3.8 cm (range 2.6–5.6) in Group SR (P = 0.009). Atrial fibrillation was induced during the ablation procedure in 7.5% and 21.3% of patients in Groups AFl and SR, respectively (P = 0.007). Overall, 29 of 188 (15.4%) patients developed new AA within 1 year of the procedure, 13.8% in Group AFl vs 17.0% in Group SR (P = 0.57). In conclusion, patients presenting for AFl ablation in SR were younger and healthier but had more atrial fibrillation induced during their ablation procedure, with a trend toward more postablation AA due to additional arrhythmia substrate.

Non-vitamin K antagonist oral anticoagulants versus warfarin for the prevention of spontaneous echo-contrast and thrombus in patients with atrial fibrillation or flutter undergoing cardioversion: A trans-esophageal echocardiography study.

Spontaneous echo-contrast (SEC) and thrombus observed in trans-esophageal echocardiography (TEE) is known as a strong surrogate marker for future risk of ischemic stroke in patients with atrial fibrillation (AF) or atrial flutter (AFL). The efficacy of non-vitamin K antagonist oral anticoagulants (NOAC) compared to warfarin to prevent SEC or thrombus in patients with AF or AFL is currently unknown. AF or AFL patients who underwent direct current cardioversion (DCCV) and pre-DCCV TEE evaluation from January 2014 to October 2016 in a single center were analyzed. The prevalence of SEC and thrombus were compared between patients who received NOAC and those who took warfarin. NOAC included direct thrombin inhibitor and factor Xa inhibitors. Among 1,050 patients who were considered for DCCV, 424 patients anticoagulated with warfarin or NOAC underwent TEE prior to DCCV. Eighty patients who were anticoagulated for less than 21 days were excluded. Finally, 344 patients were included for the analysis (180 warfarin users vs. 164 NOAC users). No significant difference in the prevalence of SEC (44.4% vs. 43.9%; p = 0.919), dense SEC (13.9% vs. 15.2%; p = 0.722), or thrombus (2.2% vs. 4.3%; p = 0.281) was observed between the warfarin group and the NOAC group. In multivariate analysis, there was no association between NOAC and risk of SEC (odds ratio [OR]: 1.4, 95% CI: 0.796–2.297, p = 0.265) or thrombus (OR: 3.4, 95% CI: 0.726–16.039, p = 0.120). In conclusion, effectiveness of NOAC is comparable to warfarin in preventing SEC and thrombus in patients with AF or AFL undergoing DCCV. However, numerical increase in the prevalence of thrombus in NOAC group warrants further evaluation.

Elevated Incidence of Atrial Fibrillation and Stroke in Patients With Atrial Flutter—A Population-Based Study

BackgroundThe risk of stroke from atrial flutter and its relationship with progression to atrial fibrillation (AF) is unclear. This study describes the incidence of AF and stroke in patients with atrial flutter, and whether atrial flutter ablation attenuates the incidence of AF and stroke. MethodsWe performed a population-based retrospective cohort study of adults with typical atrial flutter with no AF history. Using linked health administrative databases we defined 3 cohorts: (1) adult patients diagnosed with new isolated atrial flutter; (2) a contemporary, 1-to-1 matched cohort from the Ontario population; and (3) patients with isolated atrial flutter who underwent atrial flutter ablation. ResultsA total of 9339 new typical atrial flutter patients were identified and 7248 were matched to general population subjects. Over the 3-year follow-up, AF occurred in 40.4% of patients with atrial flutter, and 3.3% of the matched general population (rate ratio, 12.2; P < 0.001). Stroke occurred in 4.1% of patients with atrial flutter and 1.2% of the general population cohort (rate ratio, 3.4; P < 0.001). Among 218 patients who had an atrial flutter ablation, AF occurred in 47 (21.6%) over the following 3 years, and incidence of stroke was between 0 and 2.3%. ConclusionsPatients with isolated atrial flutter develop AF and stroke at a higher rate than the general population. Catheter ablation reduces but does not eliminate future AF incidence and stroke risk and continued anticoagulation after successful atrial flutter ablation might therefore be warranted.

Short-term outcomes of atrial flutter ablation.

Understanding the factors associated with early readmissions following atrial flutter (AFL) ablation is critical to reduce the cost and improving the quality of life in AFL patients. The study cohort was derived from the national readmission database 2013-2014. International Classification of Diseases, 9th Revision (ICD-9-CM) diagnosis code 427.32 and procedure code 37.34 were used to identify AFL and catheter ablation, respectively. The primary and secondary outcomes were 90-day readmission and complications including in-hospital mortality. Cox proportional regression and hierarchical logistic regression were used to generate the predictors of primary and secondary outcomes respectively. Readmission causes were identified by ICD-9-CM code in primary diagnosis field of readmissions. Readmission rate of 18.19% (n = 1,010 with 1,396 readmissions) was noted among AFL patients (n = 5552). Common etiologies for readmission were heart failure (12.23%), atrial fibrillation (11.13%), atrial flutter (8.93%), respiratory complications (9.42%), infections (7.4%), bleeding (7.39%, including GI bleed-4.09% and intracranial bleed-0.79%) and stroke/TIA (1.89%). Multivariate predictors of 90-day readmission (hazard ratio, 95% confidence interval, P value) were preexisting heart failure (1.30, 1.13-1.49, P < 0.001), chronic pulmonary disease (1.37, 1.18-1.58, P < 0.001), anemia (1.23, 1.02-1.49, P = 0.035), malignancy (1.87, 1.40-2.49, P < 0.001), weekend admission compared to weekday admission (1.23, 1.02-1.47, P = 0.029), and length of stay (LOS) ≥5 days (1.39, 1.16-1.65, P < 0.001). Note that 50% of readmissions happened within 30 days of discharge. Cardiac etiologies remain the most common reason for the readmission after AFL ablation. Identifying high risk patients, careful discharge planning, and close follow-up postdischarge can potentially reduce readmission rates in AFL ablation patients.