Treatment Of Typical Atrial Flutter Research Articles

Recurrent atrial flutter ablation and incidence of atrial fibrillation ablation after first-time ablation for typical atrial flutter: A nation-wide Danish cohort study

BackgroundCavo tricuspid isthmus ablation (CTIA) is considered an effective first-line treatment for typical atrial flutter (AFL). However, many patients develop atrial fibrillation (AF) after successful CTIA. Knowledge about recurrent arrhythmia after CTIA mainly comes from small cohort studies with limited follow-up. ObjectiveTo describe incidences of re-ablation for AFL and ablation for AF after first-time CTIA in a nation-wide cohort. MethodsIn the Danish National Ablation Registry we identified patients undergoing first-time CTIA during 2010–2016. Subsequent CTIA and AF-ablation procedures were identified until March 1st, 2018. We collected information on patient comorbidities in the Danish National Patient Registry. ResultsWe identified 2409 patients undergoing first-time CTIA. Median age was 66 (IQR 58–72) years, 1952 (81%) were men, and 78 (3%) patients had a history of previous ablation for AF. Acute procedural success was achieved in 2288 (95%) patients. During mean follow-up of 4.0 ± 1.7 years, 242 (10%) patients underwent CTI re-ablation and 326 (13.5%) underwent ablation for AF. Baseline characteristics associated with CTI re-ablation included prolonged procedural time, unsuccessful index CTIA, age <75 years and CHA2DS2-VASc score <2. Hypertension, history of AF-ablation, age <65 years use of a contact force sensing catheter and CHA2DS2-VASc score <2 were associated with later ablation for AF. ConclusionIn a nation-wide cohort undergoing first-time CTIA for AFL, 10% of patients underwent CTI re-ablation and 13.5% ablation for AF during mean follow-up of 4.0 ± 1.7 years. Probability of a second procedure was higher in younger patients with less comorbidities.

Further Evidence of Tricuspid Isthmus "Muscle Bundles" Using Rhythmia Mapping Technology.

Radiofrequency ablation of the cavotricuspid isthmus (CTI) is recognized as a highly successful technique in the treatment of typical atrial flutter. Transmural CTI ablation with the achievement of bidirectional conduction block is a recognized marker for success. The “muscle bundle hypotheses”

The Road Less Travelled: Cavo-Tricuspid Isthmus Ablation from a Superior Approach

Background: Cavo-tricuspid isthmus (CTI) catheter ablation is an established and effective treatment for typical atrial flutter, usually performed via a femoral approach. Unusual anatomical abnormalities such as inferior vena cava (IVC) interruption necessitate alternative approaches. Access via the superior approach has been described in the literature but not locally.

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.

Clinical evaluation of a novel 12-hole irrigated tip catheter ablation system for the treatment of typical atrial flutter—results from the Duo FLAIR clinical study

Higher current density at the proximal end of a six-hole catheter is not irrigated and thus could lead to uneven heating and possibly coagulum and charring. This study tested a novel 12-hole irrigated catheter with six additional holes at the proximal end that provides more uniform cooling during atrial flutter (AFL) ablation. A total of 188 patients (28 females, 66 ± 11years) were treated for typical AFL at 22 sites in the USA and Canada using Cool Path Duo at 50W and 45°C at an irrigation rate of 13ml/min. The results were compared to historical data from an AFL study which used a six-hole catheter with similar design. A total of 2,725 RF lesions were applied in 188 patients with a mean RF duration of 18.2 ± 11.7min per procedure. Procedural success was achieved in 96.3% (181 of 188) acutely and 98.3% (173 of 176) patients at 3months. Steam pops occurred in 0.6% of lesions (15 of 2,725) without coagulum or charring… Compared to the six-hole irrigated tip catheter, the Cool Path Duo catheter delivered more power (33.8 ± 5.9 vs. 29.7 ± 5.2W, p < 0.0001) at a lower average tip temperature (34.7 ± 1.5 vs. 37.2 ± 2.1°C, p < 0.0001) with no statistical differences in either 3-month AFL recurrence or complications. Cool Path Duo™ irrigated tip catheter is safe and effective in treating typical AFL. When compared to a six-hole irrigated tip catheter, the Cool Path Duo catheter delivers more power at a lower temperature.

Atrial fibrillation after typical atrial flutter ablation: a long-term follow-up

Although catheter ablation is an effective treatment for typical atrial flutter (TFL), atrial fibrillation may occur during follow-up. The aim of this study was to assess the frequency of postablation atrial fibrillation in patients with or without atrial fibrillation before TFL ablation. One hundred and ninety-two patients (135 men, age 68 ± 9 years) ablated for TFL were divided into two groups: group 1 (80 patients) with isolated TFL and group 2 (112 patients) with TFL and atrial fibrillation before ablation. The end-point of the study was the occurrence of documented atrial fibrillation after ablation. Several predetermined variables were tested with regard to atrial fibrillation occurrence. The patients' perception of the frequency and severity of arrhythmia-related symptoms was evaluated before and after ablation by means of the Symptom Checklist Frequency and Severity scale (SCFSS). At least one episode of atrial fibrillation was recorded in 18 (22.5%) group 1 and 52 (46%) group 2 patients (P = 0.001), during a follow-up of 1086 ± 825 and 1126 ± 962 days, respectively. On multivariate analysis, independent predictors of atrial fibrillation occurrence in group 1 were the number of preablation episodes of TFL and the younger age of the patients. The 37 group 2 patients who continued to have paroxysmal or persistent atrial fibrillation episodes after ablation showed a significant decrease in atrial fibrillation incidence and hospitalizations. SCFSS significantly improved in the 63 group 2 patients in whom it was evaluated. On long-term follow-up, after ablation of isolated TFL, more than three-quarters of patients remained free from atrial fibrillation. Conversely, in patients with preablation atrial fibrillation, TFL ablation reduced the number of atrial fibrillation episodes as well as the number of hospitalizations and arrhythmia-related symptoms.

Right Coronary Artery Damage during Cavotricuspid Isthmus Ablation

Radiofrequency ablation of the cavotricuspid isthmus is the first-line treatment for typical atrial flutter. Despite the close proximity of the right coronary artery (RCA) to the cavotricuspid isthmus, only four cases of arterial injury have been reported during radiofrequency ablation, all detected postablation by inferior ST elevation. Here, we report atrioventricular (AV) conduction delay during coronary sinus pacing as a possible early sign of RCA involvement and review the previous literature on RCA damage and variations of AV nodal circulation.

The continuing challenge of typical atrial flutter ablation: it is the anatomy! (Again)

This editorial refers to ‘Anatomical variations of the right coronary artery may be a source of difficult block and conduction recurrence in catheter ablation of common-type atrial flutter’ by H.U. Klemm et al., on page 1608 Linear ablation of the inferior vena cava-tricuspid isthmus (CTI) has become the standard treatment for typical atrial flutter (AFL), the most common regular atrial tachycardia in clinical practice. The reasons for making the CTI the ablation target were its position as an obligatory path closing circular activation in the lower right atrium, its relative narrowness, good accessibility, and its safe distance to the atrioventricular junction. The accessibility of the CTI from the femoral vein approach did initially create expectations of an easy ablation procedure; however, 15–20% of cases pose a significant challenge, needing prolonged radiofrequency (RF) applications and long procedure times. Initial ablation procedures were performed during AFL, applying RF with electrodes 4 mm in length, a power limit of 50 W, and using AFL interruption and non-inducibility as the endpoints, and recurrence rates were 30–50%. When a bidirectional, persistent CTI block became the endpoint, recurrence rates fell to a mere 3–5%.1 The definition of CTI block as the ablation endpoint allowed performing ablation during sinus rhythm, improving catheter stability in some cases. Further progress was made by designing special catheter curves or using guiding sheaths to improve stability of the ablation electrode on the CTI, but the main breakthrough was the use of larger electrodes (8–10 mm in length) allowing the … *Corresponding author. Tel: +34 91 683 0781; fax: +34 91 624 7313, Email: fgarciacosio.hugf{at}salud.madrid.org

Left atrial volume index as a predictor for occurrence of atrial fibrillation after ablation of typical atrial flutter

Radiofrequency catheter ablation of the cavotricuspid isthmus (CTI) is effective in the treatment of typical atrial flutter (AFL) and atrial fibrillation (AF). AF and AFL often coexist. However, AF often occurs following successful ablation of CTI. The aim of this study was to investigate the predictors of concomitant AF following successful ablation of AFL. We enrolled 122 patients [59.1 ± 11.3 years, male 100 (82.0%)] with typical AFL, who received successful ablation of the CTI. They were followed up at outpatient clinic (24.6 ± 25.7 months). Twelve-lead electrocardiogram and Holter monitoring were used to confirm the diagnosis of recurrent AFL or AF. We assessed prior history of AF, structural heart disease, left ventricular ejection fraction, left atrial diameter (LAD), left atrial volume index (LAVI), and AFL cycle length. Among the 122 ablated patients, 15 (12.3%) had recurrent AFL and 33 (27.0%) had recurrent AF. In univariate logistic analysis, LAD and LAVI could significantly predict the recurrence of AF after AFL ablation. However, multivariate logistic regression analysis found that the independent predictor of recurrent AF was LAVI. An LAVI of 42.6 mL may allow for the differentiation between only AFL and AFL with concomitant AF with 69.0% sensitivity and 69.8% specificity. LAVI might be a useful predictor for occurrence of AF after ablation of typical AFL.

Randomized Comparison of Multipolar, Duty‐Cycled, Bipolar‐Unipolar Radiofrequency Versus Conventional Catheter Ablation for Treatment of Common Atrial Flutter

Radiofrequency (RF) catheter ablation has been established as an effective and curative treatment for atrial flutter (AFL). Approved methods include a drag-and-drop method, as well as a point-by-point ablation technique. The aim of this study was to compare the acute efficacy and procedural efficiency of a multipolar linear ablation catheter with simultaneous energy delivery to multiple catheter electrodes against conventional RF for treatment of AFL. Patients presenting to our department with symptomatic, typical AFL were enrolled consecutively and randomized to conventional RF ablation with an 8-mm tip catheter (ConvRF) or a duty-cycled, bipolar-unipolar RF generator delivering power to a hexapolar tip-versatile ablation catheter (T-VAC) group. For both groups, the procedural endpoint was bidirectional cavotricuspid isthmus block. Sixty patients were enrolled, 30 patients each assigned to ConvRF and T-VAC groups. Total procedure time (40.2 ± 15.8 min vs 60.5 ± 12.7 min), energy delivery time (8.5 ± 3.7 min vs 14.7 ± 5.2 min), radiation dose (14.5 ± 3.5 cGy/cm² vs 31.7 ± 12.1 cGy/cm²), and the minimum number of RF applications needed to achieve block (4.2 ± 2.4 vs 8.9 ± 7.2) were significantly lower in the T-VAC group. In 7 patients treated with the T-VAC catheter, bidirectional block was achieved with less than 3 RF applications, versus no patients with conventional RF energy delivery. The treatment of typical AFL using a hexapolar catheter with a multipolar, duty-cycled, bipolar-unipolar RF generator offers comparable effectiveness relative to conventional RF while providing improved procedural efficiency.

Spanish Catheter Ablation Registry. 9th Report of the Spanish Society of Cardiology Working Group on Electrophysiology and Arrhythmias (2009)

This article reports the findings of the 2009 Spanish national Catheter Ablation Registry. Data were collected in two ways: retrospectively using a standard questionnaire and prospectively from a central database. Each center chose its own preferred method of data collection. Data were collected from 59 centers. The total number of ablation procedures carried out was 8546, giving a mean of 145 ± 101 procedures per center. The three most frequently treated conditions were atrioventricular nodal reentrant tachycardia (n = 2341; 27%), typical atrial flutter (n = 1859; 21.7%) and accessory pathways (n = 1758; 20.5%). The fourth most common condition was atrial fibrillation (n = 1188; 14%), the number of which has grown by 44% since the 2008 registry. The overall success rate was 93%, major complications occurred in 1.9%, and the mortality rate was 0.046%. Data from the 2009 registry show that the number of ablations carried out continued to increase and exceeded 8000 for the first time. In addition, they show, in general, a higher success rate and a lower number of complications. Cavotricuspid isthmus ablation, as treatment for typical atrial flutter, continued to be the second most common procedure. There was a substantial increase in the number of catheter ablations performed for atrial fibrillation compared with previous years.

Incidence of atrial fibrillation during very long-term follow-up after radiofrequency ablation of typical atrial flutter

Radiofrequency ablation is an effective treatment for typical atrial flutter (AFL) but long-term results may be hampered by atrial fibrillation (AF). To determine the incidence and predictors of AF during very long-term follow-up after radiofrequency ablation of typical AFL. From November 1998 to December 2000, patients who underwent successful radiofrequency ablation for cavotricuspid isthmus-dependent AFL in our centre were followed prospectively. Of the 135 patients followed (mean age: 62+/-11 years), 69 (51%) had structural heart disease. Mean left ventricular ejection fraction was 52+/-11%. Patients were analysed according to preablation AF history: group 1 included patients with AFL (N=71); group 2 included patients with AFL and AF (N=64). During a median [interquartile range] follow-up of 7.8 [7.0-8.4] years, new-onset or recurrent AF was experienced by 99 (73%) patients: 44 (62%) in group 1 and 55 (86%) in group 2. Although most episodes occurred in the first 2 years postablation, AF prevalence increased continuously over time. Preablation AF history predicted AF occurrence (hazard ratio: 2.10, 95% confidence interval: 1.40-3.14; p=0.001), as did left atrial diameter (hazard ratio: 1.05 per 1 mm increase; 95% confidence interval: 1.02-1.08; p<0.001). AF evolved to become permanent in 24% of group 1 and 47% of group 2 patients (p=0.005). During long-term follow-up, most patients will experience AF after ablation of typical AFL. Preablation AF history and left atrial enlargement predict postablation AF occurrence.

Incidence and predictive factors of atrial fibrillation after ablation of typical atrial flutter

Although cavotricuspid isthmus radiofrequency catheter ablation is considered curative therapy for typical atrial flutter, many patients develop an atrial fibrillation after ablation. The purpose of our study was to determine the incidence and the predictive factors of post-ablation atrial fibrillation. One hundred and forty eight consecutive patients underwent cavotricuspid isthmus ablation for the treatment of typical atrial flutter between January 2004 and December 2005 in our electrophysiological department. Complete cavotricuspid isthmus block was successfully obtained in 96.6% of the patients. At the end of the electrophysiological study a sustained atrial fibrillation was inducible in 20 patients (13.5%). During an average follow-up of 21.3 +/- 8.2 months, atrial fibrillation occurred in 27% of the patients. Univariate analysis identified four parameters correlated with post-ablation atrial fibrillation among the 21 parameters tested: the young age of the patients, a prior history of atrial fibrillation, an inducible atrial fibrillation, and a paroxysmal atrial flutter. Only inducible atrial fibrillation and paroxysmal atrial flutter were independent factors linked to atrial fibrillation after ablation. In our study the incidence of atrial fibrillation after cavotricuspid isthmus radiofrequency catheter ablation is 152 per 1,000 patient-years, i.e. 25 times higher than the incidence of atrial fibrillation in the general population of the same age. Twenty five percent of the patients who had neither prior history of atrial fibrillation nor structural heart disease suffered from atrial fibrillation during a mean follow-up of 21.3 +/- 8.2 months. All these results suggest that atrial flutter and fibrillation could be manifestations of a more general electrophysiologic disease. They emphasize the need for all these patients to benefit from regular, long-term cardiological follow-up after cavotricuspid isthmus ablation because of the high incidence of atrial fibrillation. Treatment with antiarrhythmic and antithrombotic agents should also be adapted to these factors.

Incidence of Atrial Fibrillation Post‐Cavotricuspid Isthmus Ablation in Patients with Typical Atrial Flutter: Left‐Atrial Size as an Independent Predictor of Atrial Fibrillation Recurrence

Atrial fibrillation and atrial flutter often coexist. The long-term occurrence of atrial fibrillation in patients presenting with atrial flutter alone is unknown. We report the long-term follow-up in patients who underwent cavotricuspid isthmus ablation for treatment of lone atrial flutter. Between January 1997 and June 2002, 632 patients underwent cavotricuspid isthmus ablation for the treatment of typical atrial flutter at the Cleveland Clinic Foundation. Three hundred sixty-three patients were included in this study and followed for a mean duration of 39 +/- 11 months. The mean duration of atrial flutter symptoms was 12 +/- 5 months. Mean left-atrial size and left-ventricular ejection fraction were 4.2 +/- 0.8 cm and 47 +/- 13%, respectively. After a mean follow-up time of 39 +/- 11 months, 13% (48 of 363) of the patients remained in sinus rhythm. Five percent (18 of 363) of patients experienced recurrence of atrial flutter only. Sixty-eight percent (246 of 363) experienced the onset of atrial fibrillation and 14% (51 of 363) experienced recurrence of atrial flutter and the new onset of atrial fibrillation. Overall, 82% (297 of 363) of the patients experienced new onset of drug refractory atrial fibrillation. Left-atrial size was a predictor of atrial fibrillation recurrence post-atrial flutter ablation. At long-term follow-up, approximately 82% of patients post-cavotricuspid isthmus ablation for atrial flutter developed drug refractory atrial fibrillation. This finding suggests that elimination of atrial flutter might delay, but does not prevent, atrial fibrillation. Evidence suggests both arrhythmias may share common triggers and such patients may derive a better long-term benefit from anatomical ablative treatment of atrial fibrillation as well.

Safety and efficacy of cryothermal and radiofrequency catheter ablation in treatment of typical atrial flutter

Safety and efficacy of cryothermal and radiofrequency catheter ablation in treatment of typical atrial flutter

Ablação do flutter atrial típico: estudo prospectivo e randomizado do cateter irrigado fechado versus cateter com eletrodo distal de 8 mm

Both ablation catheters with closed irrigated system and 8mm tip-catheters have been shown to be more effective for typical atrial flutter radiofrequency (RF) ablation when compared to conventional 4 mm tip catheter. Considering the differences in complexity and costs of both systems, a prospective study was designed to compare the efficacy and safety of cooled-tip and 8mm-tip catheters for atrial flutter ablation. Fifty-two consecutive patients underwent RF ablation of cavotricupsid isthmus (CTI) for the treatment of typical atrial flutter, using catheter with closed irrigation system (n=26) or 8 mm-tip catheter (n=26). The RF pulses were applied point-by-point for 60 seconds, with power limited at 50 w for the irrigated catheter and by temperature control (60 degrees/70 w) for the 8 mm catheter. The CTI block was successfully performed in 98.1%. Four patients in the irrigated group needed to switch to the other group. There was no significant difference with regard to ablation parameters, such as total time of RF ablation (591.1+/-309.0 s vs 486.2+/-250.8 s), total procedure duration (86.4+/-23.6 vs 78.1+/-22.5 min) and time of fluoroscopy (17.0+/-6.7 vs 15.4+/-4.6 min). During follow-up of 10.6 months in average, one patient in the irrigated group had recurrence of typical atrial flutter. Efficacy and safety of CTI ablation was comparable between both techniques (irrigated catheter and 8 mm-tip catheter). The complexity of irrigated catheter makes it less competitive.

Catheter selection for ablation of the cavotricuspid isthmus for treatment of typical atrial flutter

Radiofrequency catheter ablation (RFA) represents the first line therapy of the cavotricuspid isthmus-dependent atrial flutter (CTI-AFL) with a high efficacy and low secondary effects. RFA of CTI-dependent AFL can be performed by using various types of ablation catheters. Recent evaluations comparing externally cooled tip RFA (ecRFA) catheters and large-tip (8 mm) catheters have revealed that these catheters have a higher efficacy for CTI-AFL ablation compared to 4-mm catheters. The reliability of RFA catheters for AFL is variable and an optimal catheter selection may enhance the RFA effectiveness. The main goal of this article is to review the elements that improve the management of CTI RFA. Preliminary examinations of histopathologic and anatomical elements that may interfere with conventional CTI RFA are presented. Experimental studies concerning the electrobiology of large-tip and cooled-tip catheters are compared. The different catheter designs between cooled-tip and 8-mm-tip catheters are examined (size of the deflectable curve, rotation stability, and size of the distal nonsteerable catheter part) because of their critical role in CTI RFA results. A thorough review of clinical trials of each catheter is presented, and comparison of both catheters in this clinical setting is analyzed. In addition, the role of CTI morphology on AFL RF duration is underlined such as the value of right atrial angiography as an adjunct tool for CTI RFA catheter selection. Based on randomized studies, 8-mm-tip catheters seem to be more effective for ablation in case of straight angiographic isthmus morphology. On the other hand, ecRFA catheters appear to be more effective in cases of complex CTI anatomy or difficult CTI RFA. To reduce X-ray exposition and RFA application time, few studies report that CTI angiographic evaluation before RFA allows a catheter selection based on both CTI morphology and length. Moreover, preliminary data of randomized studies showed that an angiographic isthmus evaluation may predict both the effectiveness of a RFA catheter and the risk of an expensive catheter crossover.

Effects of different catheter ablation strategies in treatment of typical atrial flutter complicated with paroxymal atrial fibrillation

To evaluate the clinical effects of different catheter ablation strategies in the treatment of typical atrial flutter complicated with paroxysmal atrial fibrillation (PAF). [CTIA, pulmonary vein segmental isolation (PVSI), CTIA + PVI] to the patients coexisted with typical atrial flutter and PAF. 66 patients with typical atrial flutter complicated with PAF were divided into 3 groups: Group A (n = 30), undergoing cavotricuspid isthmus ablation, (CTIA), Group B (n = 17), undergoing pulmonary vein segmental isolation, (PVSI), and Group C (n = 19), undergoing CTIA + PVSI. Follow-up was conducted for 30.5 weeks +/- 10.4 weeks. The clinical curative effects, operation safety, and complication were evaluated. The recurrence rate of typical atrial flutter within 12 weeks after operation of Groups A and C were 13.3% and 10.5% respectively, both significantly lower than that of Group B (52.9%, both P < 0.05) without no significant difference between Group A and Group C (P > 0.05). The recurrence rate of typical atrial flutter within 36 weeks after operation of the Groups A, B, and C were 10%, 11.8%, and 10.5% respectively, without significant differences among these 3 groups (all P > 0.05). The recurrence rates of PAF within 12 weeks and 30 weeks after operation of Groups B and C were 29.4% and 31.6%, and 23.5% and 26.3% respectively, all significantly lower than those of Group A (46.7% and 73.3% respectively, all P < 0.05) without significant o differences between Groups B and C. In patients with both typical atrial flutter and PAF, pure CTIA has a good effect on typical atrial flutter, whereas the PAF recurrence rate is higher; Pure PVSI has a good control of typical atrial flutter while curing PAF; PVSI + CTIA only reduces the early recurrence of typical atrial flutter, however, has no advantage in long-term follow up.

The radiofrequency ablation of atrial flutter

This care study presents the management of a 66-year-old man with typical atrial flutter. Complications of atrial flutter are hear t failure and stroke. The management of this man involved rate control, anticoagulation, cardiovascular risk reduction and referral for radiofrequency ablation. Radiofrequency ablation is a safe and effective first-line treatment for typical atrial flutter and has a number of advantages over long-term pharmacological management. Issues such as quality of life and patient choice also need to be addressed by health professionals when formulating management plans.