Catheter Ablation Of Atrial Flutter Research Articles

Validation of bidirectional cavotricuspid isthmus block using electrocardiographic imaging

Abstract Background The validation of bidirectional cavotricuspid isthmus (CTI) block following catheter ablation for typical atrial flutter (AFL) involves endocavitary manoeuvres using multiple catheters. The diagnostic capacity of electrocardiographic imaging (ECGi) as a non-invasive tool to confirm bidirectional CTI block may simplify the procedure but its benefit has not been investigated so far. Purpose To evaluate the diagnostic capacities of a novel imageless ECGi system in detecting bidirectional CTI block during AFL catheter ablation. Methods A total of 34 patients were consecutively included in a prospective single-centre study. Atrial activation maps were derived from a novel imageless ECGi system when pacing the septal and lateral aspects of the CTI, gauging the technology's capacities to detect bidirectional block by measuring transisthmic intervals (TII) and observing wave-front collision patterns. TII reflects the time taken for electrical activation to cross the CTI during pacing and we measured both the absolute value and the increase relative to its baseline value. The bidirectional CTI block was assessed by endocavitary manoeuvres using a multipole catheter as the gold-standard. We conducted a blind assessment of the diagnostic capacities of ECGi over endocavitary manoeuvres considering maps from the septal and lateral pacing to determine clockwise and counterclockwise CTI block, respectively. Results Our study established clear benchmarks for diagnosing CTI block using ECGi (Figure 1). Regarding the assessment of clockwise CTI block, the presence of a wave-front collision pattern at the CTI yielded a positive predictive value (PPV) of 91% and negative predictive value (NPV) of 69%. Furthermore, ROC analysis pinpointed 100 ms and 30 ms as the optimal threshold for TII absolute value (PPV=89%, NPV =78%) and TII increase from baseline (PPV=91%, NPV =65%), respectively. Taking together, the combination of these three parameters offered high diagnostic capacities (PPV=87%, NPV=90%). Regarding counterclockwise CTI block, the TII absolute value alone was a reliable predictor, with a threshold derived from ROC analysis of 115 ms providing a PPV of 77% and a NPV of 83% (Graphical abstract). Conclusion These results highlight the efficacy of ECGi in CTI block assessment, promising a streamlined and accurate diagnostic approach (Graphical abstract). The use of a single ablation catheter coupled with ECGi to assess the bidirectional CTI block offers a simplified and efficient alternative to traditional dual catheter techniques.ECGi-based CTI block assessment methodGraphical abstract

Major in-hospital complications after catheter ablation of cardiac arrhythmias: individual case analysis of 43 031 procedures.

In-hospital complications of catheter ablation for atrial fibrillation (AF), atrial flutter (AFL), and ventricular tachycardia (VT) may be overestimated by analyses of administrative data. We determined the incidences of in-hospital mortality, major bleeding, and stroke around AF, AFL, and VT ablations in four German tertiary centres between 2005 and 2020. All cases were coded by the G-DRG- and OPS-systems. Uniform code search terms were applied defining both the types of ablations for AF, AFL, and VT and the occurrence of major adverse events including femoral vascular complications, iatrogenic tamponade, stroke, and in-hospital death. Importantly, all complications were individually reviewed based on patient-level source records. Overall, 43 031 ablations were analysed (30 361 AF; 9364 AFL; 3306 VT). The number of ablations/year more than doubled from 2005 (n = 1569) to 2020 (n = 3317) with 3 times and 2.5 times more AF and VT ablations in 2020 (n = 2404 and n = 301, respectively) as compared to 2005 (n = 817 and n = 120, respectively), but a rather stable number of AFL ablations (n = 554 vs. n = 612). Major peri-procedural complications occurred in 594 (1.4%) patients. Complication rates were 1.1% (n = 325) for AF, 1.0% (n = 95) for AFL, and 5.3% (n = 175) for VT. With an increase in complex AF/VT procedures, the overall complication rate significantly increased (0.76% in 2005 vs. 1.81% in 2020; P = 0.004); but remained low over time. Following patient-adjudication, all in-hospital cardiac tamponades (0.7%) and strokes (0.2%) were related to ablation. Major femoral vascular complications requiring surgical intervention occurred in 0.4% of all patients. The in-hospital mortality rate adjudicated to be ablation-related was lower than the coded mortality rate: AF: 0.03% vs. 0.04%; AFL: 0.04% vs. 0.14%; VT: 0.42% vs. 1.48%. Major adverse events are low and comparable after catheter ablation for AFL and AF (∼1.0%), whereas they are five times higher for VT ablations. In the presence of an increase in complex ablation procedures, a moderate but significant increase in overall complications from 2005-20 was observed. Individual case analysis demonstrated a lower than coded ablation-related in-hospital mortality. This highlights the importance of individual case adjudication when analysing administrative data.

Abstract 15828: Variations in the Use of Catheter Ablation for Atrial Flutter Among US Adults Using Nationwide Inpatient Sample (NIS) Database

Introduction: Atrial flutter is one of humans' most common cardiac arrhythmias. Catheter ablation is the definitive treatment for typical atrial flutter because of a very high success (>95%) and low complication rate. Therefore, we explored variations in the use of catheter ablation for atrial flutter among US adults. Methods: We used the 2017-2019 National Inpatient Sample (NIS) for this analysis. Multivariable logistic regression analysis was used to assess factors associated with catheter ablation among patients with atrial flutter in the US. Results: Of the 1406220 adults hospitalized with a diagnosis of atrial flutter, 66825 (4.75%) underwent ablation for atrial flutter. Blacks were less likely to undergo ablation for atrial flutter compared to Whites (AOR=0.91; 95% CI: 0.85-0.99, P = 0.01). Similarly, patients with Medicare (AOR=0.88; 95% CI: 0.83-0.92, P=0.00), and Medicaid insurance (AOR=0.80; 95% CI: 0.74-0.87, P=0.00) were less likely to have catheter ablation for aflutter compared to those with private insurance. Other significant predictors of the likelihood of getting an ablation included younger age 0.98 (95% CI: 0.97-0.98, P=0.00), and lower co-morbidity burden ( class II with AOR of 0.65; 95% CI: 0.62-0.69 and Class III with AOR of 0.43; 95% CI: 0.41-0.46 compared to class I). No gender disparity was observed in this analysis, females had an AOR of 0.96 (95% CI: 0.92-1.00) Conclusions: Findings highlight significant racial and insurance-related disparities in access to catheter ablation for atrial flutter. Addressing social and structural issues underlying these disparities is critical for achieving equitable outcomes for patients with atrial flutter.

PO-04-136 VISUALIZATION OF LOW AMPLITUDE ELECTROGRAMS WITH A NOVEL RECORDING SYSTEM IN THE ELECTROPHYSIOLOGY LABORATORY

Electrical noise, particularly power line noise at 50-60 Hz, is frequently generated by electrical equipment present in the electrophysiology (EP) laboratory. High frequency, low amplitude intracardiac unipolar and bipolar electrograms (EGMs) are particularly susceptible to distortion from this type of noise. The aim of this study was to evaluate a novel EP recording system developed to address this issue. To measure baseline noise and the smallest identifiable EGMs in a range of procedures. We enrolled patients undergoing catheter ablation of atrial flutter, atrial fibrillation (de novo as well as redo), SVT and conduction system pacemaker implantation. The peak-to-peak noise and intracardiac unipolar and bipolar signal amplitude was measured manually, initially side-by-side using the LabSystem (LS) Pro (Boston Scientific) and ECGenius System (CathVision) systems and then ECGenius System alone (Figure). EGMs were chosen to represent the lowest peak to peak amplitude of signals where information was of interest. A total of 37 consecutive patients were enrolled. The amplitude of the baseline noise measured on the LSPro system using standard filtering including a 60Hz notch filter was > 0.040 mV bipolar and > 0.100 mV unipolar. In contrast, on the ECGenius System the measured peak to peak baseline noise amplitude had a mean value of 0.010 ± 0.004 mV and 0.014 ± 0.018 mV for bipolar and unipolar EGMs, respectively using standard filter settings (Table). A mean noise level of 0.011 mV ± 0.005 was measured through a pacing lead allowing signals as low as 0.023 mV to be observed. The ability to visualize low amplitude intracardiac EGMs is essential during EP procedures. However, EGMs, especially unipolar EGMs, can be obscured by noise, most commonly due to power line interference. We demonstrate that a novel EP recording system had a mean noise level of only 0.010 mV with a low-end of 0.004 mV for bipolar signals. This allowed identification of intracardiac EGMs with a peak-to-peak voltage as low as 8 μV. These characteristics offer the possibility of improving outcomes during EP procedures and may also facilitate physiologic pacing through the identification of small His and bundle branch potentials.Tabled 1ECGenius measurements of baseline noise and lowest clinical EGM amplitude observed by catheter and trace typeBaselineLowest ClinicalminmeanStd.Dev.minmeanSt.Dev.Catheter TypeOrion0.0050.0130.0140.0270.0560.085Pentarray0.0040.0090.0050.0080.0290.035Ablation0.0050.0110.0030.0230.0370.015Pacemaker Lead0.0080.0110.0050.0230.0950.149EGM TypeUnipolar0.0080.0140.0180.0350.0900.138EGM TypeBipolar0.0040.0100.0040.0080.0330.026 Open table in a new tab

Achieving bi-directional conduction block during catheter ablation is not enough to prevent recurrence of cavo-tricuspid isthmus dependant atrial flutter: Role of subclinical conduction.

Achieving bi-directional conduction block, as assessed by differential pacing and change in activation along tricuspid annulus (TA), across the cavo-tricuspid isthmus (CTI), is considered a satisfactory end point during catheter ablation of atrial flutter (AFL). To assess role of subclinical conduction by observing polarity reversal of local bipolar signals from RS to QR pattern lateral to the line of ablation, in predicting recurrence of CTI dependant AFL after ablation in patients with bidirectional conduction block. Of 683 patients undergoing ablation of CTI dependent AFL, 73 (10.6%) patients underwent redo flutter ablation and were evaluated further. The mean age was 60.8 years and 51% were males. Evidence of bidirectional block by differential pacing and change is activation along multipolar catheter and reversal of local bipolar signals from RS to QR pattern lateral to the line of ablation, during the 1st and subsequent procedure, were studied. 60% patients had confirmed bidirectional block of which 71% had lack of voltage reversal, at the end of 1st procedure. All patients with bidirectional block with lack of reversal of bipolar signals, after the first procedure had recurrence of AFL whereas only 3/11 (27%) people with bidirectional block and with absence of subclinical conduction had recurrence of AFL. Achieving bidirectional conduction block is not sufficient to prevent recurrence of AFL after CTI ablation. Reversal of local bipolar signals, from RS to QR pattern along with achieving bidirectional conduction delay would reduce recurrence of AFL, post ablation.

Woman With Chest Pain and Dyspnea

A 48-year-old woman presented to the emergency department with 1 day of chest discomfort, dyspnea, and orthopnea. She was discharged from the hospital 2 days ago after radiofrequency catheter ablation for atrial flutter. Her ECG and chest radiography were both normal. Bedside cardiac point-of-care ultrasound showed a large hyperechoic mass in the left atrium (Figure 1, Figure 2, Videos E1 and E2).Figure 2Ultrasonographic apical view demonstrated the hyperechoic mass (arrowhead) occupying most of the left atrial cavity.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Left atrial intramural hematoma post–catheter ablation. Cardiac computed tomography (CT) demonstrated a left atrial intramural hematoma causing compression of the left ventricular inflow tract with a small pericardial effusion (Figure 3). The patient was admitted to the coronary care unit for monitoring and observation; at 4 days, her repeat cardiac CT demonstrated a stable hematoma, and she was discharged after 7 days. At 1 month, her cardiac CT later showed nearly complete resolution. The overall incidence of ablation-related complications has been decreasing over the last few decades as institutions have gained experience and is estimated at 3% although the incidence of left intramural hematoma is far lower.1Gupta A. Perera T. Ganesan A. et al.Complications of catheter ablation of atrial fibrillation: a systematic review.Circ Arrhythm Electrophysiol. 2013; 6: 1082-1088Crossref PubMed Scopus (188) Google Scholar, 2Giudicatti L. King B. Lee F. et al.Left atrial intramural hematoma post-ablation of supraventricular tachycardia: a rare complication treated successfully.JACC Case Rep. 2020; 2: 223-226Crossref PubMed Scopus (2) Google Scholar, 3Haseeb S. Kutyifa V. Left atrial intramural hematoma after radiofrequency catheter ablation: beware of the unexpected.JACC Case Rep. 2020; 2: 227-229Crossref PubMed Scopus (2) Google Scholar Bedside ultrasound is an excellent method to ascertain cardiac and pericardial complications. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxMGNkZTUyZjdjMGJhYWUzMjQ5MGM5NGJjYTYzYjBhNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc1NzYwNTA0fQ.O-IwG7CyTItrbzjRokj7gIU1Hzxu7dNLt3ApgNoAp9vDpBMfLbEKgpWSk8sYHetH5Vz8WHXqbQ2Cb5ss4AUxggfsnbvgk0JbJyfkCH7qyJs_mP-wTCLwzS1Q24JLTBWQzQVzmb3YjKPAXSYRppC7irO7R1G0L9eWvgTh4CYPzGjHjYnv2SZGDAMs0B5-rwKF39aZX7nFRt2qVGQ1gzziYuZU7BY5WSC-bAXoQgWYkdsxh3rEwPY1IN8h_8YHSsy0G96mAfUj-9g-tlRjDXkNzYSbSTYYk63S5RN2LKLDaPROMI3LmTc3921xvygReltJLzubF18dMY8W8ZXs1VoEEw Download .mp4 (2.58 MB) Help with .mp4 files LAIH video clip ApicaleyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlMTg0MjJlMWFjNTVlOTkzNWI1ZmI5NGZlOGY4ZGY0MSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc1NzYwNTA0fQ.EB2L0u__X22_jVC7TfUdeOdBiJ54hHMfy-4yLe29r_pmQiuv9u1aPe0vPHZuU6Gta7yZtdjWEv4vM4DVkRUyRfUihNIJp6x7yAEW-u4KvyI_2cHb3rxHPVvJkUmR4OQZepK8wffdyCytPuZoN79dpyFd2u_Clbq5jd5vI-nHfRJjhn4zM5IMBDQvyFUV76g4F1kw3qsR4hxw5sRff8b2xHM8b4MYHfXYg4AGLO8UsxEmtzVLk0EuiZiQKhRcu3UfvK0DzSas9uhkqp1W1COQY-JQOUk3ToqQMMRQZSDR5W9Orz9-lVB4P_CTTeBgyVXSwVAD8wUaYCq3tXqOU9EdTA Download .mp4 (2.87 MB) Help with .mp4 files LAIH video clip PLAX

Atypical atrial flutter catheter ablation in the era of high-density mapping.

Mapping and ablating atypical atrial flutters (AAFLs) have evolved greatly with advances in high-density 3D mapping systems over the last years. The objectives are to evaluate the feasibility of AAFL catheter ablation based on high-density mapping and minimizing entrainment and to better characterize AAFL circuits. Consecutive patients who underwent AAFL ablation using the EnSite Precision™ system and HD Grid™ mapping catheter (Abbott, Chicago, IL) between 06/2018 and 1/2022 were included. Mitral isthmus-dependent and roof-dependent AAFLs were classified as conventional circuits. All other AAFL circuits were classified as non-conventional circuits and were defined based on the location of the critical isthmus. Sixty-two patients underwent AAFL ablation (mean age 68±11 years). A total of 95 AAFLs were mapped and 92 (97%) were successfully ablated. Fifty-three (85%) patients had a previous AF/AFL ablation. Forty-four (46%) AAFL circuits were classified as conventional and 51 (54%) as non-conventional. Conventional AAFL circuits had longer critical isthmuses (19.0±9.0 vs 10.8±6.3mm, p<0.001), a lower prevalence of slow conduction at the critical isthmus (59% vs 86%, p=0.005), and a longer radiofrequency time to AAFL termination (117±119 vs 51±66 s, p=0.002). Entrainment was attempted in 19 (20%) flutters and its use declined significantly over the study period. Procedural success rates remained high whether entrainment was used or not. Freedom of any atrial tachycardia was 65% over a follow-up of 13.8±9.0 months. AAFL catheter ablation can be achieved with high procedural success rate using a contemporary strategy based on high-density mapping alone. Non-conventional circuits are frequent and present unique electrophysiological characteristics.

Abstract 14471: Cardiac Sarcoidosis Presenting With Hiccups - A Case Report

Introduction: Sarcoidosis is a multi-system disorder of unknown etiology that is commonly associated with hilar lymphadenopathy and granulomas. Cardiac involvement is less common, however, sarcoidosis is a known cause of restrictive cardiomyopathy. It typically presents as new-onset arrhythmias or heart failure, although cases of sudden cardiac death have been reported. Case presentation: We present a case of a 56-year-old male with a known history of pulmonary sarcoidosis, not on any active treatment, who presented to the emergency department with one week of continuous hiccups every few seconds associated with non-exertional dyspnea. Initial CT scan of the chest showed multiple stellate-like ground-glass opacities and progression of bronchiectasis. Troponins were negative. On the initial EKG, he was found to be in atrial flutter and was admitted to the general medical floor. He was given baclofen and the hiccups resolved over the next 24 hours. Cardiology was consulted for suspected cardiac sarcoidosis and they recommended transferring the patient to the tertiary care center for further evaluation. Upon arrival, the patient underwent catheter ablation for atrial flutter and he returned to the sinus rhythm after the procedure. The initial nuclear scan with gallium was not suggestive of cardiac sarcoidosis, however, subsequent cardiac MRI showed cardiac involvement. Due to the high risk of arrhythmias, the patient was scheduled for implantable cardioverter defibrillator placement before discharge. Treatment with steroids was deferred until after the PET scan could be completed. The patient was discharged in stable condition and interrogation of the device found it to be well functioning and with no significant arrhythmias noted. Conclusions: Presentation of cardiac sarcoidosis can be variable and should be considered in any patient with a known history of sarcoidosis who presents with atypical symptoms at or above the level of the diaphragm, such as hiccups or with new-onset arrhythmias.

Randomized comparison of atrioventricular node re-entry tachycardia and atrial flutter catheter ablation with and without fluoroscopic guidance: ZeroFluoro study.

Interventional cardiology procedures may expose patients and staff to considerable radiation doses. We aimed to assess whether exposure to ionizing radiation during catheter ablation of supraventricular tachycardia (SVT) can be completely avoided. In this prospective randomized study, patients with SVT (atrioventricular re-entrant tachycardia n = 94, typical atrial flutter n = 29) were randomly assigned in a 1:1 ratio to catheter ablation with conventional fluoroscopic guidance (CF group) or with the EnSite Precision mapping system [zerofluoro (ZF) group]. Acute procedural parameters, increased stochastic risk of cancer incidence and 6-month follow-up data were assessed. Between May 2019 and August 2020, 123 patients were enrolled. Clinical parameters were comparable. Median procedural time was 60.0 and 58.0 min, median fluoroscopy time and estimated median effective dose were 240 s vs. 0 and 0.38 mSv vs. 0 and arrhythmia recurrence was 5% and 7.9% in the CF and ZF groups, respectively. The acute success rate was 98.4% in both groups. No procedure-related complications were reported. At an average age of 55.5 years and median radiation exposure of 0.38 mSv, the estimate of increased incidence was approximately 1 in 14 084. The estimated mortality rate was 1 per 17 857 exposed persons. The procedural safety and efficacy of the zero-fluoroscopic approach are similar to those of conventional fluoroscopy-based ablation for atrioventricular nodal re-entrant tachycardia and atrial flutter. Under the assumption of low radiation dose, the excessive lifetime risk of malignancy in the CF group due to electrophysiology procedure is reasonably small, whilst totally reduced in zero fluoroscopy procedures.

Anatomical variants of the cavotricuspid isthmus in patients undergoing catheter ablation for atrial flutter and/or atrial fibrillation

Abstract Background We evaluated the differences in the anatomy of the cavotricuspid isthmus (CTI) by assessing image loops provided by intracardiac echocardiography (ICE) in patients who underwent ablation for atrial flutter and/or atrial fibrillation. Purpose CTI is an essential component of the reentrant circle in isthmus–dependent atrial flutter (CTI-AFL) and a target for catheter ablation. In some patients, CTI anatomy may be responsible for a difficult procedure. The aim of this study is to describe in details the anatomical variants of this structure. Methods We included a group of 138 patients, who underwent cardiac ablation for atrial flutter and/or atrial fibrillation between August 2020 and January 2021. Intracardiac echocardiography was employed during the intervention to evaluate the morphology of CTI. Analysis was focused on size, shape, presence of sub-eustachian pouch (excavation more than 5 mm) or presence of prominent Eustachian ridge (ER, embryologic remnant of the valve of the IVC) and mobility of the structure. Results The length of CTI measured during ventricular systole averaged at 38,4mm (min 22,5mm, max 60mm). The most frequent pattern was a flat CTI without sub-eustachian excavation or with excavation less than 5mm (71 patients; 51.4%). A pouch (excavation more than 5mm) was observed in 41 pts (29.7%), where the deepest pouch reached 10,5mm. Prominent ER was present in 58 pts (42%). The remaining 26 of CTIs (18.8%) were classified in the “unclassifiable” category with deviations from common anatomic variants - substantial convexity, pronounced trabeculation of isthmus or double pouch. We observed 14 CTIs (10.1%), where the structure was partially or in full extent detached from the diaphragm, sliding during cardiac contractions. In addition to the described morphology, Chiari's network was observed in 18 pts (13%). In reference to mobility, 53 pts (38.4%) presented with hypermobile CTI with a difference in size of more than 1/3 between the diastole and systole. Moreover, we looked into differences of CTI related to BMI, left atrial volume index (LAVi) and ejection fraction of the left ventricle. A positive correlation was found between LVEF and mobility of CTI. Hypermobile CTI was present in 42.2% of pts with normal LVEF compared to only 18.9% of pts with reduced EF (EF less than 50%). Similar results were observed in pts with non-dilated LA, where hypermobile CTI was present in 51.9% of pts compared to only 35.1% of pts with dilated LA with LAVi &amp;gt;28 ml/m2 (see table below). Conclusions We observed a substantial differences in the anatomy of the CTI, which could play an important role in catheter ablation of this structure. Besides the prominent ER, significant sub-eustachian pouch and hypermobility appear to be variants predisposing to difficult ablation. Funding Acknowledgement Type of funding sources: None. CTI variants related to EFLV, BMI, LAViCTI detached from the diaphragm

Electrophysiological characteristics of epicardial to endocardial breakthrough in intractable cavotricuspid isthmus-dependent atrial flutter.

Epicardial to endocardial breakthrough (EEB) exists widely in atrial arrhythmia and is a cause for intractable cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL). This study aimed to investigate the electrophysiological features of EEB in EEB-related CTI dependent AFL. Six patients with EEB-related CTI-dependent AFL were identified among 142 consecutive patients who underwent CTI-dependent AFL catheter ablation with an ultra-high-density, high-resolution mapping system in three institutions. Activation maps and ablation procedure were analyzed. A total of seven EEBs were found in six patients. Four EEBs (including three at the right atrial septum and one in paraseptal isthmus) were recorded in three patients during tachycardia. The other three EEBs were identified at the inferolateral right atrium (RA) during pacing from the coronary sinus. The conduction characteristics through the EEB-mediated structures were evaluated in three patients. Two patients only showed unidirectional conduction. Activation maps indicated that CTI-dependent AFL with EEB at the atrial septum was actually bi-atrial macro-reentrant atrial tachycardia (BiAT). Intensive ablation at the central isthmus could block CTI bidirectionally in four cases. However, ablation targeted at the inferolateral RA EEB was required in two cases. Meanwhile, local potentials at the EEB location gradually split into two components with a change in activation sequence. EEB is an underlying cause for intractable CTI-dependent AFL. EEB-mediated structure might show unidirectional conduction. CTI-dependent AFL with EEB at the atrial septum may represent BiAT. Intensive ablation targeting the central isthmus or EEB at the inferolateral RA could block the CTI bidirectionally.

Abstract 15958: Comparison of In-hospital Outcomes of Patients Undergoing Catheter Ablation for Typical versus Atypical Atrial Flutter

Introduction: Catheter Ablation (CA) is indicated as definitive therapy for patients with atrial flutter (AF) which is unresponsive to medical therapy. While atrial flutter may be typical (TAF) or atypical (AAF), there is a paucity of data regarding in-hospital outcomes of patients undergoing CA. Methods: This retrospective cohort study used the Nationwide Inpatient Sample to identify all patients above 18 years who underwent CA between 2015 and 2017. Individuals were identified using ICD-10-CM/PCS for TAF, AAF and CA. Statistical analysis was performed comparing TAF to AAF. Results: A total of 17,390 patients underwent CA for AF, with 33% having AAF and 67% TAF. Patients with TAF were younger (median 67 years vs. 68 years), with lower proportion of females (29.6% vs. 42.8% p≤0.05 for both) compared to patients with AAF. TAF group had higher rates of emergent admission (85.7% vs. 65.5% p≤0.05). Interestingly, subjects with AAF had earlier interventions than patients with TAF (≤3 days of admission, 76.4% vs. 71% p≤0.05). Patients with TAF have a higher rate of hypertension, diabetes, smoking, heart failure, liver disease, and chronic obstructive pulmonary disease (p≤0.05 for all). However, patients with AAF had increased prior strokes and percutaneous coronary interventions (PCI) (p≤0.05 for both). The mean CHA2DS2-VASc score was found to be 2.3 in AAF compared to 2.1 in TAF (controlled for comorbidities, p≤0.05). Multivariable regression showed a significantly higher proportion of cardiogenic shock, acute coronary syndrome, sepsis, cardiac catheterization, PCI, thromboembolism event, transfusion, and longer length of stay in patients with TAF (p≤0.05 for all). Although we found that patients with AAF have significant higher rates of cardioversion, implantation of cardiac device, pericardial complications, and increased hospital charges (p≤0.05 for all), no significant difference was found in mortality. Conclusion: In this retrospective cohort study, we found higher complication rates in CA of patients with TAF, even when adjusting for pertinent comorbidities, but no difference in in-hospital all-cause mortality. Variation in CA depending upon the mechanism of AF may underlie these differences, and warrant further study.

Impact of catheter ablation for atrial flutter on mortality and hospital readmission rates in patients with heart failure and reduced ejection fraction

Abstract Background The effectiveness of catheter ablation as a management modality amongst patients with coexisting atrial flutter (AFL) and heart failure with reduced ejection fraction (HFrEF) is scarcely studied. Methods Appropriate ICD 10 codes were applied to the 2016 and 2017 National Readmission Database (NRD) to isolate patients having coexistent AFL and HFrEF including who had undergone an ablation. All-cause mortality at the end of 1 year was used as a primary outcome. Readmission due to AFL, heart failure (HF) and other causes were secondary outcomes. The hazard ratios were generated using Cox regression analysis while the time to event analysis was demonstrated with the Kaplan Meier curves. Results Out of a total of 9966 patients with AFL and HFrEF, 1980 (24.79%) patients underwent catheter ablation. The primary outcome, all-cause mortality (2.8% vs. 4.6%, HR: 0.610, 95% CI: 0.460–0.808, p=0.001) at the end of 1 year was significantly lower. Significant difference was also noted amongst two groups when it came to secondary outcomes such as readmissions due to AFL (1.6% vs. 6.3%, HR: 0.247, 95% CI: 0.173–0.354, p&amp;lt;0.001), HF (8.2% vs. 11.4%, HR: 0.693, 95% CI: 0.587–0.819, p&amp;lt;0.001) and other causes (29.4% vs. 37.1%, HR: 0.735, 95% CI: 0.673–0.804, p&amp;lt;0.001) Conclusion Ablative intervention amongst AFL patients with concomitant HFrEF showed a significant reduction in all-cause mortality. It also leads to significant reductions in readmissions due to AFL, HF and other causes at the end of one year. Outcomes of AFL and HFrEF Funding Acknowledgement Type of funding source: None

Impact of catheter ablation for atrial flutter on mortality and hospital readmission rates in patients with heart failure and preserved ejection fraction

Abstract Background The availability of real-world data regarding the impact of the catheter ablation in patients with concomitant atrial flutter (AFL) and heart failure with preserved ejection fraction (HFpEF) is limited. Methods 2016 and 2017 National Readmission Database (NRD) was subjected to appropriate ICD-10 codes to identify and extract patients having coexistent atrial flutter and heart failure with preserved ejection fraction including who had undergone ablation. At 1 year, all-cause mortality was utilized as the primary outcome while readmissions due to AFL, heart failure (HF) and any other causes were designated as secondary outcomes. Kaplan Meier curves were used for a time to event analysis. Cox proportional hazard regression was used to generate hazard ratios. Results Out of a total 6099 patients with AFL and HFpEF, 906 (14.85%) underwent catheter ablation. At 1 year all cause mortality (3%, vs. 4.4%, HR: 0.661, 95% CI: 0.444–0.985, p=0.042) and readmissions due to AFL (2.3% vs. 5.3%, HR: 0.424, 95% CI: 0.272–0.661, p&amp;lt;0.001) were significantly less among ablation group. Readmission due to HF (9.3% vs. 9.7%, HR: 0.938, 95% CI: 0.745–1.182, p=0.587) and other causes (37% vs.40.3%, HR: 0.926, 95% CI: 0.825–1.040, p=0.193) did not show any significant difference in outcomes at the end of 1 year. Conclusion The utilization of catheter ablation amongst AFL patients with concomitant HFpEF showed a significant reduction in all-cause mortality and readmission due to AFL. However, it did not show any significant changes in readmissions due to HF or other causes at the end of one year. Outcomes of AFL and HFpEF Funding Acknowledgement Type of funding source: None

Electrophysiological Characteristics and Outcomes of Radiofrequency Catheter Ablation of Atrial Flutter in Children with or Without Congenital Heart Disease.

There are scarce studies on radiofrequency catheter ablation (RFCA) of atrial flutter (AFL) in the pediatric population. This study therefore aimed to investigate the clinical features and RFCA of AFL in children with or without congenital heart disease. Data from 72 consecutive children (44 males; mean age, 6.1 ± 3.8 [0.9-15.0] years; and mean weight, 23.6 ± 13.9 [8.1-72.0] kg) undergoing RFCA for AFL from 2009 to 2019 were retrospectively reviewed. Thirty-three patients had normal cardiac structure and 39 had congenital heart disease (CHD) of whom 29 had undergone surgical repair and developed AFL at a mean of 3.1 ± 2.5years later. Fifty-nine patients (84%) presented with persistent AFL. Five patients (7%) had cardiac dysfunction with LVEF of 30-48%, which normalized after ablation. Overall, acute success rate of ablation was 99% and recurrence rate was 18% at 0.5-10years of follow-up. No procedure-related complications were identified. All 33 patients with normal cardiac structure had cavotricuspid isthmus (CTI)-dependent AFL. Among patients who had undergone corrective surgery for CHD, 15 (52%) had CTI-dependent AFL, 4 (14%) had surgical incisional scar reentrant AFL and the remaining 10 (34%) had both CTI-dependent and scar reentrant AFL. Success rate (100% vs. 97%, P = 1.0000) and recurrence rate (21% vs. 16%, P = 0.7008) were similar between patients with and without CHD. Overall, sick sinus syndrome (SSS) was found in 42% (30/72) of patients with AFL, with an incidence of 39% (13/33) among patients with normal cardiac structure and 59% (17/29) among those who underwent surgery for congenital defects. Permanent pacemakers (PM) were implanted in 53% (16/30) of patients with SSS after ablation. RFCA therefore appeared efficacious and safe for treatment of pediatric AFL. The mechanisms underlying AFL after corrective surgery for CHD are complex, including CTI-dependent macro-reentrant, scar reentrant, or a combination of both. SSS is not rare among pediatric AFL cases, with approximately half of patients needing PM implantation.

Catheter ablation of atrial flutter: Critical isthmus identification and localization

Catheter ablation of atrial flutter: Critical isthmus identification and localization

Catheter ablation of atrial flutter: Critical isthmus identification and localization

Catheter ablation of atrial flutter: Critical isthmus identification and localization

P1446Cavo-tricuspid atrial flutter catheter ablation with a real zero fluoroscopic approach

Abstract Funding Acknowledgements none Background Catheter ablation(CA)is the first-line therapy of cavo-tricuspid isthmus(CTI)atrial flutter. Sometimes an inversion of ablation catheter is necessary to obtain a complete bidirectional line block. Purpose.The aim of this study was to describe this CA approach using electro-anatomical mapping(EAM)system with a zero-fluoroscopy(ZF)approach.Methods.Ninety-four patients that performed CA of CTI were retrospectively enrolled since 2017 to 2019.The studied population were divided in two groups.Group1(44patients) was composed of patients who underwent CA using ablation catheter without shaft visualization catheter(NSVC)on EAM.Group2(50patients)was composed of patients who underwent CA using ablation catheter with a shaft visualization(SVC). The catheter was looped at the Eustachian ridge after 200 seconds of RF without elimination of local electrogram. Results.ZF CTI ablation was obtained in all patients of group 2 without fluoroscopy use.In six patients of group 1, the catheter inversion was used to obtain a complete CTI block.In NSVC group, the catheter inversion was obtained using fluoroscopy to avoid damages during loop of catheter ablation.In overall population studied SVC had a linear correlation with ZF approach(β=0.629;p &amp;lt; 0.001). No differences were documented regarding acute and late success,complications.The procedural time between two groups was similar (Group1:83.4 ± 22.4 vs.Group2:80.2 ± 34.7minutes). The detailed results were summarize in table1. Conclusions.A real ZF catheter ablation of atrial flutter is safe and feasible.The use of SVC could improve the reproducibility of a successful zero-fluoroscopy CA.The visualization of the shaft’s catheter permit to invert the catheter safely to overcome anatomic complexity of some CTI without fluoroscopy use. detailed results Detailed results Group 1(44 CA) Group 2(50 CA) p value Procedure time (min) 83.4 ± 22.4 80.2 ± 34.7 NS AFL at begin CA (n.) 36 23 FT (min) 9.1 ± 9.8 0 ± 0 &amp;lt; 0.001 PWRF (W) 32 ±2.5 33.6 ±2.2 NS CA line length (mm) 28.1 ± 4.1 27.9 ± 5.5 NS Total RF (min) 27.8 ± 6.3 13.6 ± 7.2 &amp;lt; 0.01 SR during RF 35 23 Conductional block after 30 min 44 50 NS 6 months recurrences 1 1 NS AFL: atrial flutter; FT: fluoroscopy time; PWRF: power radiofrequencies; CA line length: length of line of radiofrequencies; RF: radiofrequencies; SR: sinus rhythm. Detailed results. Abstract Figure.

Real-life safety of atrial flutter ablation in the era of NOACs. The French Global Flutter Study

Cavotricuspid isthmus (CTI) radiofrequency ablation (RFA) is considered a first-line therapy to achieve rhythm control in patients with typical atrial flutter (AFL). Determine the incidence and risk factors for developing bleeding complications in patients takingnon-vitamin K anticoagulants (NOAC) versus vitamin K antagonists (VKA) and undergoing an atrial flutter catheter ablation in everyday clinical practice. It is a multicenter, observational, prospective study of patients with AFL undergoing a CTI RFA. Eligible patients had been taking apixaban (2.5 or 5 mg twice daily), rivaroxaban (15 or 20 mg once daily), dabigatran (110 or 150 twice daily) or VKA for ≥ 3 weeks before the procedure, and were followed for 30 days afterwards. A total of 477 patients, 69,7 ± 10.9 [interquartile range 29, 96] years, 80% male, mean CHA2DS2-VASc score 2.4 ± 1.5 were enrolled at 25 academic/nonacademic centres in France. 84 patients (17.6%) were receiving rivaroxaban (68 patients on 20 mg/day, and 16 patients on 15 mg/day). 89 (18.6%) patients were receiving dabigatran 65 patients on 300 mg/day and 24 on 220 mg/day. 244 (51.15%) patients were receiving apixaban (210 on 10 mg/day, and 34 patients on 5 mg/day). 60 (12.57) patients were receiving VKA. The mean INR before procedure was 2.7 ± 1.8. The most prevalent concomitant disorders were hypertension (53%), diabetes (20%) and vascular disease 87 (18%). Mean creatinine concentration was 98 ± 45micromol/L, median weight was 84 ± 18 kg and mean creatinine clearance (Cockcroft-Gault) was 80 ± 33 mL/min. Overall, 28 patients were switched to unfractionated heparin or enoxaparin. The median duration of switch was 6 ± 14 hours. Complications were reported at 30 days, and included only 1 (1.6%) bleeding event in patient receiving VKA (hematoma). Every day practice of AFL ablation in patients receiving NOACs is safe. No complications were reported in these patients on NOACs.

Safety of uninterrupted direct oral anticoagulants for ambulatory common atrial flutter catheter ablation: A propensity score–matched cohort study

Same-day home discharge after common atrial flutter catheter ablation (CAFCA) is a feasible, safe, and cost-effective practice, but there are currently no data for patients treated with direct oral anticoagulants (DOAs). We evaluated the safety, efficacy, and feasibility of ambulatory CAFCA in patients treated with DOAs compared with those treated with vitamin K antagonists (VKAs). Patients scheduled for isolated and elective ambulatory CAFCA in our tertiary university center between 2009 and 2019 were included. Propensity score for anticoagulant type was calculated from age, sex, body mass index, HAS-BLED and CHA2DS2-VASc scores, chronic kidney disease, associated antiplatelet treatment, procedure duration, and number of femoral venipunctures. Propensity score matching yielded 820 patients (mean age 67 ± 11 years). Catheter ablation was performed under uninterrupted VKA (n = 410; international normalized ratio 2.5 ± 0.6) or uninterrupted DOA (n = 410). The procedural success rate was 91%, and the effective same-day discharge rate was 93%. The occurrence of the primary end point, defined as any early and clinically significant bleeding (Bleeding Academic Research Consortium classification ≥ 2) at 1 week, was similar between patients treated with DOAs and those treated with VKAs (2.9% vs 3.7%; P = .70). Female sex, high HAS-BLED score, and prolonged procedure duration were independently associated with the primary end point. Uninterrupted DOA regimens are safe for patients undergoing ambulatory CAFCA in a high-volume center with a dedicated ambulatory unit and standardized procedural and postoperative management.