Radiofrequency Ablation Of Atrial Flutter Research Articles

Radiofrequency Ablation of Atrial Flutter in 59-Year-Old Patient with Uncorrected Ebstein’s Anomaly

Radiofrequency Ablation of Atrial Flutter in 59-Year-Old Patient with Uncorrected Ebstein’s Anomaly

Comparative Effectiveness of Various Radiofrequency Ablation Catheters in the Ablation of Typical Atrial Flutter.

Although ablation of typical atrial flutter (AFL) can be easily achieved with radiofrequency energy (RF), no studies compare the effectiveness of different ablation catheters. Our study aimed to compare the efficacy of various types of ablation catheters in treating typical AFL. We analyzed patients with AFL who underwent RF ablation by a single operator at our institution. Successful ablation was evidenced by a bidirectional conduction block (trans-isthmus conduction time ≥ 130ms or double potentials ≥ 90ms). Logistic regression was used to compare success rate and linear regression to compare lesion time. Out of 222 patients, only six did not meet the success criteria (2.7%). The catheters used were non-irrigated, large-tip, internally irrigated (Chili II Boston Scientific), and externally irrigated (non-force-sensing) catheters (Cool Path, Abbott). An externally irrigated force-sensing catheter (TactiCath, Abbott) was used with > 10 gm of force and (LPLD) setting (30 W- 45°C- 60s), and high-power short-duration (HPSD) setting (50 W- 43°C - 12s). No complications were encountered. The catheter type had no statistically significant association with ablation success. With the use of externally irrigated catheter with contract force-sensing and HPSD settings, statistically significantly shortening of lesion time was achieved 758.3s, [CI - 1128.29, - 388.35s] followed by LPLD by 419.0s [CI - 808.49, - 29.47s]. The typical atrial flutter radiofrequency ablation procedure had a high success rate, which was not influenced by the type of ablation catheter. Contact force ablation catheter and HPSD are associated with shorter total lesion time.

Abstract 14772: Comparing Efficacy of Venous Closure Devices in Patients Undergoing Atrial Fibrillation and Atrial Flutter Ablation: A Retrospective Review

Introduction: Vascular closure devices have shown marked improvement in patient comfort and time to ambulation after undergoing atrial fibrillation (AF) and atrial flutter (AFL) radiofrequency ablation. They have been proven superior to manual closure and Figure of 8 suture in terms of pain control and time to ambulate. However, data comparing different vascular closure devices is sparse. Hypothesis: To compare the efficacy of venous closure devices Methods: We retrospectively reviewed 100 patients at our institution who underwent AF and AFL radiofrequency ablation. We aimed to assess the difference in time to ambulation, device failure, pain control and vascular complication rate between the two commonly used venous closure devices (VASCADE and PERCLOSE). Results: A total of 100 patients (50 in each arm) were included in the study. The mean age was 67.6 + 9.3 years and 73% patients were men. The two groups were well balanced with respect to baseline demographics and clinical characteristics except for coronary artery disease (24% VASCADE vs. 14% PERCLOSE, p <0.001). No significant difference was observed in time to ambulate between PERCLOSE (2 + 0.21 hours) vs VASCADE (2 + 0.23 hours); p=0.74. 8% patients (n=4) in VASCADE arm required additional PERCLOSE to achieve hemostasis. 4% (n=2) patients in PERCLOSE arm required opioids for pain management; compared to none in VASCADE arm. No closure device related complications were observed in either arm. Conclusions: Both venous vascular closure systems offer similar efficacy in terms of time to ambulate. However, PERCLOSE was used in addition to VASCADE in a few instances to achieve hemostasis.

Effectiveness of various radiofrequency ablation catheters in the treatment of typical atrial flutter

Abstract Introduction Although ablation of typical atrial flutter (AFL) can be easily achieved with radiofrequency energy (RF), there are no studies that compare effectiveness of different ablation catheters. Our study aimed to compare the effectiveness of various types of ablation catheters in the treatment of AFL. Methods We analysed patients with AFL who underwent RF ablation by a single operator at our institution. Successful ablation was evidenced by presence of bidirectional conduction block (trans-isthmus conduction time ≥130 ms, or doubling of baseline conduction time, or presence of double potentials ≥90ms). Logistic regression was used to compare success rate and linear regression to compare lesion time. Results Out of the 222 patients, only 6 patients did not meet success criteria (2.7%). Catheters used were 8 mm tip in 16 patients, internally irrigated (Chili II Boston Scientific) in 47 patients, externally irrigated (non-force sensing) catheters (CoolPath, Abbott) in 40 patients. Externally irrigated force sensing catheter (Tacticath, Abbott) was used with >10 gm of force and (LPLD) setting (30W-45°C-60 sec) in 50 patients, and high-power short duration (HPSD) setting (50W-43°C −12 sec,) in 70 patients. No complications were encountered. Catheter type had no statistically significant association with ablation success. In terms of lesion time, HPSD catheter statistically significantly shortened lesion time by 758.3s, [CI −1128.29, −388.35s] followed by LPLD by 419.0s [CI −808.49, −29.47s]. Table 1 shows the lesion time difference for the catheters used as compared with 8 mm tip. Conclusions Typical atrial flutter radiofrequency ablation procedure had a high success rate, not influenced by type of ablation catheter. Contact force ablation catheter on HPSD is associated with shorter total lesion time. Funding Acknowledgement Type of funding sources: None.

Is prophylactic ablation of the cavotricuspid and peri-incisional isthmus justified in patients with postoperative atrial flutter after right atriotomy?

The two most common postoperative atrial flutter (AFL) circuits after right atriotomy are the cavotricuspid isthmus (CTI) dependent and the lateral, peri-incisional. We investigated whether radiofrequency ablation (RFA) of both circuits results in more favorable long-term outcomes. Single-center retrospective cohort study of consecutive patients who underwent RFA of AFL after open-heart surgery. The effect of surgery type and RFA strategy on AFL recurrence was evaluated. One hundred and forty-two patients (mean age 64.5 ± 12.7 years, 65.% male) were enrolled. Patients with right atrial (RA) flutter (n = 124) were divided into two groups based on the index RFA procedure: only one RA circuit was ablated (Group 1, n = 84, 67.7%) or both the CTI and the peri-incisional circuit ablated (Group 2, n = 40, 32.3%). The previous open-heart surgery was categorized based on the extension of the RA incision: limited (Type A) or extended (Type B) atriotomy. After a mean follow-up of 36 ± 28 months, flutter recurrence was not different among patients with limited RA atriotomy (25% vs. 22% in Groups 1A and 2A, respectively, p = 1.0). However, after type B surgery, ablation of both AFL circuits was associated with a reduced recurrence rate (63% vs. 26% in Groups 1B and 2B, respectively, p = .002). In patients with postoperative RA flutter after extended right atriotomy, ablation of both the CTI and the peri-incisional isthmus significantly reduces the AFL recurrence rate. Prophylactic ablation of both isthmi, even if not proven to support reentry, is reasonable in this population.

Prevention of Atrial Fibrillation After Atrial Flutter Ablation With Ramipril (from the PREFACE Study)

The clinical efficacy of the inhibitors of the renin-angiotensin-aldosterone system (RAAS) as an upstream therapy for atrial fibrillation (AF) prevention is controversial. No study has itemized so far the role of RAAS inhibitors in AF prevention after atrial flutter (AFL) ablation. This trial aims to investigate the effect of ramipril compared with placebo on AF occurrence in patients hospitalized for AFL ablation without structural heart disease. The Prevention of Atrial Fibrillation by Inhibition Conversion Enzyme (ICE) After Radiofrequency Ablation of Atrial Flutter (PREFACE) trial was a prospective, multicenter, randomized, double-blind, double-dummy trial depicting the AF occurrence during a 12-month follow-up as the primary end point. A total of 198 patients hospitalized for AFL ablation were enrolled in the trial and randomized to placebo or ramipril 5mg/day. Patients were followed up during 1year after AFL ablation using 1-week Holter electrocardiogram at 3, 6, 9, and 12months. The intention-to-treat population encompassed 97 patients in the ramipril group and 101 patients in the placebo group. The primary end point, such as AF occurrence during the 1-year follow-up, was not different between the 2 groups (p = 0.96). Secondary end points, including the occurrence of supraventricular arrhythmia (p = 0.50), heart failure, stroke, and death, were not different between the 2 groups. Safety outcome parameters, including serious adverse events leading to treatment disruption (p = 0.10), hypotension, impairment of renal function, and elevated serum potassium level, also were not different between the 2 groups. In conclusion, RAAS inhibition using ramipril does not reduce AF occurrence in patients facing AFL ablation during the 1-year follow-up.

Coronary Sinus Electrograms May Predict New-onset Atrial Fibrillation After Typical Atrial Flutter Radiofrequency Ablation (CSE-AF).

Complex fractionated electrograms (EGMs) of the coronary sinus electrograms (CSEs) are employed as a target during radiofrequency ablations (RFA) of atrial fibrillation (AF). Anatomically, CSEs includes both of left atrium (LA), coronary sinus musculature and right atrium (RA) electrograms. To determine the significance of fractionated CSE and delayed potentials as a predictor of new-onset AF after radiofrequency ablation (RFA) of isolated atrial flutter (AFL). Consecutive patients underwent AFL ablation. Fractionated and/or continuous discrete activities were recorded from coronary sinus electrograms during sinus rhythm and during pacing. Earliest CSE to the S nadir or peak R in milliseconds was recorded and considered as propagation delay for EGMs. Forty patients were included during a mean follow-up period of 55.1± 15.8 months. Twenty patients (50 %) developed AF while the remaining 20 patients maintained sinus rhythm(SR) during the follow-up period. Proximal and mid CSEs were significantly fractionated in AF group compared to group with no AF development (65 % and 60% Vs. 35 % and 30 %, p = 0.03, respectively). However, during pacing from distal duo-decapolar catheter (pole 1-2), distal CSEs alone were significantly fractionated (p < 0.05) compared to SR group. Significant delayed propagation of proximal CSE during pacing and in sinus rhythm were observed in AF group (12.3 ± 9.2 ms vs 7.1 ± 3.6 ms, p = 0.03) and (7.2 ± 2.9 ms Vs 8.1 ± 4.6 ms, p= 0.02) in the same order. Incidence of AF is associated with fractionated proximal and mid CSE in sinus rhythm and distal CSE during paced rhythm after isolated AFL ablation. Delayed proximal CSE propagation is correlated with AF incidence.

Decreased operator X-ray exposure by optimized fluoroscopy during radiofrequency ablation of common atrial flutter.

To evaluate operator and patient irradiation during radiofrequency ablation (RFA) of common atrial flutter (AF) using three different fluoroscopy settings. A total of 38 patients who underwent RFA of AF with three different fluoroscopy settings (low dose, standard dose and collimated field) were included. Twelve patients (11 men, 1 woman; mean age, 67±12 [SD]years) were included in the low dose group (3.75 frames per second), 13 patients (13 men; mean age, 66±8 [SD]years) were included in the standard dose group (7.5 frames per second) and 13 patients (13 men; mean age, 71±12 [SD]years) were included in the collimated field group (7.5 frames per second). Operator and patient exposure were compared between groups. No differences in procedure time and radiation exposure were found between the three groups. In the low dose group, mean operator X-ray exposures of eye-lens (4.7±2.9 [SD]μSv/h; range: 0.9-10.5μSv/h), whole body (1.6±1.2 [SD]μSv/h; range 0.5-3.6μSv/h) and hand skin (11.1±10.8 [SD] μSv/h; range 2.4-35.4μSv/h) were significantly lower than those in the standard dose group (P<0.001). Significant patient dose reduction was found between low dose group (0.7±0.4 [SD]Gy/h; range: 0.3-0.9Gy/h) and standard (1.7±0.5 [SD]Gy/h; range: 0.8 to 3.9Gy/h) and collimated (1.8±0.5 [SD]Gy/h; range: 0.7-3.0Gy/h) groups (P<0.01). The use of a low dose setting (3.75 f/s) during fluoroscopy dramatically reduces operator's irradiation during RFA of AF by a mean of 90%.

Long-term outcomes in patients with ablation of clockwise and counterclockwise forms of typical atrial flutter

The atrial flutter of common type, with more frequent typical counterclockwise form, may occasionally present with clockwise form. The latter might be induced by clockwise functional block within cavotricuspid isthmus (CTI) of a premature atrial complex originating from the right atrium. As physiopathology might differ, we sought to compare long-term outcomes in patients who underwent CTI radiofrequency ablation for atrial flutter according to the electrical activation (clockwise or counterclockwise) at baseline. All patients who underwent CTI radiofrequency ablation between 2000 and 2010 in the cardiology department of a four-hospital institution were included for analysis. Association with atrial fibrillation (supposed to be more frequently seen in case of left atrial origin of the arrhythmia), all-cause mortality, thromboembolic events, and atrial fibrillation occurrence were compared between patients with clockwise (group A) and counterclockwise (group B) CTI-dependant flutter. There was no significant difference at baseline (age, sex, heart failure, medication, hypertension, diabetes and stroke) between patients in group A ( n = 41) and B ( n = 831). Concomitant atrial fibrillation (AF) was present in 43% of patients in group A and 37% of patients in group B ( P = 0.39). Deaths ( n = 38), stroke/thromboembolic events ( n = 30) and evolution to permanent AF ( n = 53) were recorded after a follow-up of 826 ± 1024 days. There was no significant difference between both groups for occurrence of death of any cause (hazard ratio 1.31, 95%CI 0.53–3.23 in group A compared to group B, P = 0.55), stroke and thromboembolic events (hazard ratio 2.17, 95%CI 0.65–7.14, P = 0.20) and evolution to permanent AF (hazard ratio 2.27, 95%CI 0.78–6.25, P = 0.13). Despite very different prevalence rates, clockwise and counterclockwise forms of CTI dependent atrial flutter occur in similar populations and seem associated with relatively similar outcomes.

Pulmonary Vein Isolation for Atrial Fibrillation Can Be Achieved With Low Radiation Exposure

Atrial fibrillation is common and management by pharmacotherapy is limited by modest efficacy and significant toxicities. Pulmonary vein isolation (PVI) is a safe and effective alternative in select patients with atrial fibrillation. However, prolonged procedure time raises concerns of health risks from radiation exposure. This study aims to determine the significance of radiation exposure from PVI. In this study, we retrospectively reviewed patient demographics, fluoroscopy time, entrance skin dose and dose area product in 80 cases of PVI, radiofrequency ablation for atrial flutter and diagnostic coronary angiogram performed in our institution. Compared to other procedures, patients who underwent PVI were younger (age, mean±standard error of mean, 59.4±1.1 years old, p<0.0001) and were more likely to be male (82%, p<0.001). Body mass index was similar between the three groups. The median (and interquartile range) fluoroscopy time was similar between PVI (20.8 and 13.1-30.7mins) and flutter ablation (17.6 and 11.1-26.1mins) but longer than diagnostic angiography (4.2 and 2.3-6.7mins, p<0.0001). Entrance skin dose was similar between PVI and flutter ablation groups but significantly higher in the diagnostic angiography group, with median and IQR for PVI vs. flutter ablation vs. diagnostic angiography, 100.4 (52.8-179.9) vs. 73.2 (37.0-142.1) vs. 393.5 (276.1-555.6) mGy (p<0.0001). Dose area product in PVI (1831.2 and 887.7-3460.8cGycm2) was higher than flutter ablation (1077.8 and 452.9-2410.2cGycm2, p<0.05) but lower than the diagnostic angiography group (3446.8 and 2341.9-5283.1cGycm2, p<0.0001). The fluoroscopy time and entrance skin dose for PVI decreased over time, likely due to increased operator experience. Despite prolonged procedure time, radiation exposure from PVI was comparable to, or lower than, other fluoroscopy-guided cardiac procedures.

Ustąpienie całkowitego bloku przedsionkowo-komorowego po ablacji typowego trzepotania przedsionków

A 58-year-old man was admitted with third-degree atrioventricular block and concomitant typical atrial flutter. In such situation the procedure consist of dual-chamber pacemaker implantation followed by cavotricuspid isthmus ablation. In presented case a decision has been made to reverse the order of standard procedures. The radiofrequency ablation of atrial flutter resulted in resolution of complete atrioventricular block and restoration of atrioventricular conduction 1:1, thus the implantation of the dual-chamber pacemaker was not necessary.

AVOID THOSE SUTURES: ATRIAL FLUTTER ABLATION AFTER A RECENT HEART TRANSPLANT

There is concern that radiofrequency ablation for atrial flutter after recent heart transplant could potentially disrupt fresh suture lines. A 55 year old man with end stage ischemic cardiomyopathy underwent bicaval orthotopic heart transplant. His postoperative course was complicated by rapid

April 2016 at a glance. Focus on cardiac remodeling, biomarkers and treatment.

Mohamed et al. show the long-term effects of volume overload induced by aortacaval shunt in mice followed by serial echocardiography until the development of reduced left ventricular ejection fraction (LVEF) and heart failure (HF). Transition to HF was characterized by reduced sarcomeric titin phosphorylation, a cause of increased sarcomeric stiffness, activation of calcium/calmodulin-dependent protein kinase II, decreased protein kinase B (Akt) phosphorylation, high oxidative stress, and increased apoptosis. These changes were worsened in Akt-deficient mice showing the critical role of this kinase.1 Tenascin-C is a large glycoprotein which appears in the extracellular matrix following tissue injury or tumor formation. Yokokawa et al. have measured it in 123 patients with dilated cardiomyopathy undergoing endomyocardial biopsy. Patients with high myocardial tenascin had worse cardiac remodeling and poorer outcomes. Diabetes and HF severity were independent determinants of its content.2 Suematsu et al. have compared valsartan and LCZ696 with a control group in streptozotocin induced diabetic mice. Compared with control and with valsartan groups, administration of LCZ696 improved LVEF and reduced LV ANP mRNA, the LV fibrotic area and TGF-β levels.3 Atrial flutter-related tachycardiomyopathy is a specific form of cardiac remodeling. Brembilla-Perot et al. report the 6 months follow-up of 1269 patients who underwent radiofrequency ablation for atrial flutter. A marked improvement in LVEF was shown in 56% of the patients who had a reduced LVEF before ablation. An ischemic etiology and prescription of antiarrhythmic drugs were associated with a lower likelihood of LVEF improvement. Patients who improved their LVEF had similar outcomes as those with a normal LVEF at baseline whereas those with a persistent low LVEF post-ablation had an almost 3-fold higher mortality rate.4 Ovchinnikova et al. have measured circulating microRNAs in 137 patients with acute HF, 20 with chronic HF, 8 with dyspnea caused by COPD exacerbation, and 41 healthy controls. Plasma levels of miRNAs were decreased in the patients with acute HF compared with all the other groups with 15 of the 226 miRNAs measured that showed a larger than a 4-fold difference. Among them, 12 were different also in the validation cohort and a prognostic value was shown for 7 of them so that their further drop within 48 hours after admission was associated with an increased risk of 180-day mortality.5 Another study shows that liver function exams were abnormal in up to 40% of the patients with acute HF enrolled in ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) and increased serum bilirubin had prognostic value also at multivariable analysis.6 Sleep-disordered breathing (SDB) is found in over half of the patients with HF and is associated with reduced quality of life and poor prognosis. Pearse and Cowie have reviewed the classification, pathophysiology, prognosis and treatment options for patients with HF and SDB. The results of the most recent trials, including SERVE-HF, are discussed.7 The effects of chronic subcutaneous (SQ) BNP administration were evaluated by McKie et al. in a double-blind, placebo controlled study in patients with asymptomatic LV dysfunction who underwent plasma volume expansion at baseline and after 12 weeks. Compared with placebo, chronic SQ, twice daily, BNP administration was associated with an increase in urinary sodium and cGMP excretion and in urine flow with a tendency to a different glomerular filtration rate response to volume expansion and to a lower LV mass.8

Stroke and Systemic Embolism After Successful Ablation of Typical Atrial Flutter.

Following successful cavotricuspid isthmus (CTI) ablation during typical atrial flutter (AFL), anticoagulation therapy is usually withdrawn. However, potential subsequent atrial fibrillation (AF) in these patients may increase embolic risk in the long term. Embolic rates in this setting have not been clearly established. Our aim was to determine the incidence of stroke/systemic embolism following radiofrequency ablation of AFL, particularly in those without a prior history of AF. After succesful AFL ablation, patients may suffer embolic complications in the long-term follow-up, mainly due to asymptomatic AF episodes. We conducted a retrospective analysis of all patients who underwent CTI ablation due to AFL in our center between 2006 and 2009. During the study period, 188 patients (mean age, 62.9 ± 8.6 years) underwent CTI ablation; 120 without prior AF were included in the study. At the end of the follow-up period (mean, 5.0 ± 2.4 years), 56.7% of patients (68/120) remained in sinus rhythm, 7/120 experienced a recurrence of AFL, and 45/120 (38%) developed AF. Ischemic stroke occurred in 11 patients and systemic embolism in 1. Of these patients, 5 had documented AF following AFL ablation. In the remaining 7 cases, previously undiagnosed AF was subsequently diagnosed at the time of stroke/embolism. Patients with AFL who undergo successful ablation are by no means free from embolic complications during long-term follow-up, mainly due to a high rate of AF development. Given the difficulties in detecting AF and the uncertainty about the temporal relation of AF and stroke, oral anticoagulation may need to be continued in those patients with underlying stroke risk factors.

0362: Atrial fibrillation after radiofrequency ablation of atrial flutter: prevalence and risk factors

Radiofrequency ablation (RFA) is the only curative treatment for typical atrial flutter (AFL) and allows stopping antiarrhythmic drugs. However, atrial fibrillation (AF) is frequent during follow-up but predictive factors of AF onset are unknown while it is necessary to diagnose it in order to apply the correct antithrombotic strategy. To determine prevalence and predictors of AF after AFL RFAAFL. From January 2012 to December 2013, patients who underwent RFA of cavotricuspid isthmus for typical atrial flutter in our centre were retrospectively included. Of 166 patients (137 men, mean age: 66.7±10 years), 61 (36.7%) had a history of AF. The mean CHA2DS2VASc and HASBLED scores were 2.49 and 1.11. Mean left ventricular ejection fraction was 53±13% and 77 (46.4%) patients had a subsequent cardiomyopathy, whereas 61 (36.7%) had a history of AF. Of 166 RFA, sinus rhythm was obtain in 160 patients and 141 (84.9%) procedures were considered as a complete success (complete isthmus block). During a mean follow up of 489±244 days, there were 7 (5%) and 9 (36%) AFL recurrence in patients with and without isthmus block respectively. New-onset or recurrent AF were experienced by 63 (39%) patients. History of AF was an independent predictive factor of AF (33 (52.4%) vs. 28 (27.2%) patients; p=0.002). The younger patients (64.4 ±11.7 vs. 68.2±9.9 years; p=0.03) and patients with lower CHA2DS2VASc score had more AF post ablation (2.16±1.53 vs. 2.70±1.57; p=0.03). After successful RF ablation, AF was frequent in patients especially in patient with AF history before AFL RFA, but also occurred in patient with lone AFL. Age and CHA2DS2VASc score were inversely associated with onset of AF. Identify AF and risk patients is crucial regarding to long-term antithrombotic therapy. Abstract 0362 – Table: predictive factors of AF No FA post ablation(N=103) FA post ablation (N=63) p Men/Women (N/N) 89/14 48/15 0.09 Age (years) 68.2+/–9.9 64.4+/–11.7 0.03* SAS 10 (9.7) 4 (6.3) 0.57 Cardiopathy 53 (51.5) 24 (38.1) 0.11 History of AF (N [%]) 28 (27.2) 33 (52.4) 0.002* Dilated LA (N [%]) 43 (41.7) 32 (50.8) 0.4 Dilated LV (N [%]) 12 (11.7) 12 (19) 0.41 LVEF <45% (N [%]) 29 (28.2) 10 (15.9) 0.09 High blood pressure (N [%]) 63 (61.2) 31 (49.2) 0.14 Age ≥75 years 29 (28.2) 15 (23.8) 0.59 Diabetes mellitus 18 (17.5) 9 (14.3) 0.66 CHA 2 DS 2 VASc 2.7+/–1.57 2.16+/–1.53 0.03* BMI (kg/m 2 ) 27.4+/–5.5 27.9+/–4.9 0.55 Creatinine clearance (Cockroft) 78.1+/–30.8 85.3+/–37.4 0.19 Creatinine clearance (MDRD) 72.8+/–22.4 73.9+/–23.7 0.76 SAS: sleep apnoea syndrome; AF: atrial fibrillation; LA: left atrial; LV: left ventricular LVEF: left ventricular ejection fraction; BMI: body mass index

0163: Management of long-term anticoagulant therapy after atrial flutter radiofrequency ablation according to associated atrial fibrillation and CHA2DS2-VASc score

Radiofrequency ablation (RFA) is the only curative treatment for typical atrial flutter (AFL) and allows stopping antiarrhythmic drugs. However, management of long-term anticoagulant therapy (LT ACT) remains unclear, especially in lone AFL successfully treated and CHA 2 DS 2 VASc score ≥1. Abstract 0163 – Table: Table Long-term anticoagulation therapy management A GROUP (N=74) B GROUP (N=63) C GROUP (N=17) AF YES (N [%]) NO (N [%]) YES (N[%]) NO (N [%]) YES (N [%]) NO (N [%]) TAC YES (N [%]) 14 (18.9) 11 (14.9) 29 (46) 20 (31.7) 4 (23.5) 0 (0) NO (N [%]) 2 (2.7) 43 (58.1) 3 (4.8) 7 (11.1) 6 (35.3) 5 (29.4) LTFUP (N [%]) 4 (5.4) 4 (6.4) 2 (11.8) AF: Atrial fibrillation ACT: anticoagulant therapy LTFUP: lost to follow up patient Assessment of long-term ACT after AFL RFA according to associated atrial fibrillation (AF) and CHA 2 DS 2 VASc score. From January 2012 to December 2013, patients who underwent RFA of cavotricuspid isthmus for typical atrial flutter in our centre were retrospectively included. Of 166 patients (137 men, mean age: 66.7±10years), 61 (36.7%) had a history of AF. The mean CHA 2 DS 2 VASc score was 2.49. The patients were classified according to theoretical indication of LT ACT (patients with a non rhythmic ACT indication excluded – N=12; 7.2%): group A (LT ACT unclear) included patients with CHA 2 DS 2 VASc score ≥1, successful RF ablation and without AF history (N=74); group B (LT ACT indicated) included patients with CHA 2 DS 2 VASc score ≥1, AF history and/or failed AFL RFA (N=63); group C (LT ACT not indicated)included patient with CHA 2 DS 2 VASc score=0 (N=17). During a mean follow up of 489±244 days, 45 (60.8), 10 (15.9%) and 11(64.7) patients stopped ACT respectively in group A, B and C differently according to AF onset (table). There were 8 (4.8%) hemorrhagic and 2 (1.2%) ischemic complications, all in patients with correct ACT management. The prevalence of AF during follow-up was 38%. After successful AFL RF ablation, ACT was frequently stopped in the absence of associated AF. However, AF was frequent even inpatients with no AF history. Ischemic and hemorrhagic complications were rare. ACT should be regularly evaluated during follow-up especially according to CHA 2 DS 2 VASc score and new onset of AF.

Sharp Potential in Cavo-tricuspid Isthmus Targeted during Typical Atrial Flutter Radiofrequency Ablation

The aim of this study was to define atrial electrograms (EGM) morphology, which could predict a conduction gap in cavo-tricuspid isthmus (CTI) during typical atrial flutter (AF) radiofrequency ablation. One hundred atrial EGM were retrospectively analysed. We demonstrated that recognising a sharp potential (short duration and high amplitude) is useful for quickly achieving CTI bi-directional block during typical AF ablation.

0029: Does the class of antiarrhythmic drug change the risk of atrial flutter in patients with atrial fibrillation or the risk of atrial fibrillation after atrial flutter ablation?

Atrial fibrillation (AF) and atrial flutter (AFL) are frequently associated. The purpose of the study was to look for the effect of antiarrhythmic drugs (AAD) on the risk of AF occurrence after radiofrequency ablation of AFL. 1121 patients, mean age 64±12 years, were referred for AFL ablation. History, data of echocardiography, antiarrhythmic drug (AAD), were collected. Patients were followed from 3 months to 10 years (mean 2.1±2.7 years). AAD was stopped after ablation except in patients with previous AF before ablation or continued otherwise. 857 patients received an AAD (n=637) or a betablocker (n=221). 356 patients (31.7%) had a history of AF prior to AFL ablation. Patients with AF prior to ablation were more likely to be female (OR=1.35, CI=1.00-1.83, p=0.05), more likely to be treated with a class I AAD (45.5% vs 7.7%), isolated or associated with beta-blockers and more likely tended to be treated with Amiodarone (36.5% vs. 31.2%, p=0.08). After ablation, 260 (23.2%) patients experienced AF. In multivariable model, AF prior to ablation (OR=1.90, CI=1.42-2.54, p<0.001) and female gender (OR=1.77, CI=1.29-2.42, p<0.001) were associated with a higher risk of AF after ablation. In patients without prior AF, Class I AAD and Amiodarone prior to AFL ablation were independently associated with higher risk of AF after ablation (OR=2.11, CI=1.15-3.88, p=0.02 and OR=1.60, CI=1.08-2.36, p=0.02 respectively). Patients with previously diagnosed AF were more likely to be treated with a class I AAD (45.5% vs. 7.7%), isolated or associated with beta-blockers (data not shown), and more likely tended to be treated with Amiodarone (36.5% vs 31.2%, p=0.08). AF occurrence after AFL ablation is frequent (>20%), especially in patients with a history of AF, in female patients, and in patients treated with Class I antiarrhythmics/Amiodarone prior to AFL. The risk was similar in patients treated with class I or III drug. In a patient referred for AFL ablation without known AF before AFL, treated with AAD, the follow-up should be careful because these patients appear at high risk of AF occurrence.

Risk of new-onset atrial fibrillation and stroke after radiofrequency ablation of isolated, typical atrial flutter.

Radiofrequency ablation (RFA) is considered a curative procedure for typical atrial flutter (AFL); however, patients remain at risk for developing new atrial fibrillation (AF). The purpose of this study was to determine the incidence and predictors of new-onset AF and stroke after RFA of isolated AFL in a multicenter cohort. The study included 315 consecutive patients who underwent successful RFA of isolated, typical AFL from 2006 to 2013 at 4 community and teaching hospitals. Patients with any history of AF prior to RFA were excluded. During 2.5 ± 1.8 years of follow-up after RFA, 80 patients (25%) developed new AF. In multivariate analysis, after adjusting for baseline medical therapy, obstructive sleep apnea and left atrial enlargement were independently associated with the development of new AF. Presence of a cardiac implantable electronic device (CIED) was associated with a 3.6-fold (95% confidence interval 1.9-6.6, P <.0001) increase in the likelihood of AF detection. New AF was detected in 48% of patients with CIED and 35% of those who underwent Holter ECG vs 19% of those with clinical follow-up only (P <.0001). Anticoagulation was stopped in 58% patients an average of 3.3 ± 4.8 months after RFA. Stroke occurred in 3 patients (1%) during the follow-up period. New AF occurs in ≥25% of patients after RFA of isolated typical AFL, but stroke is relatively rare. Obstructive sleep apnea and left atrial enlargement are risk factors for AF. The presence of a CIED significantly enhances the likelihood of detecting new AF, demonstrating the importance of arrhythmia surveillance after RFA of AFL.

New oral anticoagulants for periprocedural anticoagulation in patients undergoing atrial flutter radiofrequency ablation: A pilot survey

New oral anticoagulants for periprocedural anticoagulation in patients undergoing atrial flutter radiofrequency ablation: A pilot survey