Isthmus-dependent right atrial flutter as the leading cause of atrial tachycardias after surgical atrial septal defect repair
Abstract
Objectives The purpose of this study was to evaluate clinical and electrophysiologic characteristics of AT in patients after surgical ASD repair as well as outcome after ablation.Background Atrial tachycardias (AT) are a common complication after surgical closure of an atrial septal defect (ASD).Methods From a prospective ablation database we analyzed data of patients with a history of ASD repair who presented to our institution for AT ablation. We investigated ECG characteristics and the electrophysiologic mechanism of AT in this collective and analyzed follow-up data.Results Data of 54 patients (47.3 ± 14.5 years, 35 females) were included. In 30 patients (55.6%) ASD had been closed by direct suture, 24 patients (44.4%) had a patch for ASD repair without significant difference in terms of gender and age at the time of the procedure (p=0.234, p=0.231). In 42 patients (77.8%), electrophysiological studies were performed in AT. All patients had right atrial macro-reentrant AT. The leading mechanism was isthmus-dependent right atrial flutter in 29 patients (69.0%) with clockwise atrial activation in 41%. The mechanism of AT (typical atrial flutter (n=29), atriotomy-dependent flutter (n=7), and double loop flutter (n=5)) did not differ with regard to type of surgery. Only 70.6% of patients with proven isthmus dependent counter-clockwise atrial flutter presented with an ECG morphology typical for this mechanism. However, all clockwise typical atrial flutter patients showed the characteristic positive P-waves in the inferior leads. Of note, 83.3% of clockwise typical flutter ECGs had long isoelectric lines (mean 74.5 ms). Follow-up was complete in 45 of 54 patients. During a mean follow-up of 7.7 ± 3.7 years, 27 patients (60%) remained free of any arrhythmia, two patients had AT recurrence with different mechanisms compared to the first procedure and underwent successful ablation. Five patients (11%) developed atrial fibrillation.Conclusion Isthmus dependent right atrial flutter is the leading AT mechanism in patients with a history of ASD repair. The mechanism of atrial flutter did not differ in relation to the mode of ASD closure (direct suture versus patch closure). ECG characteristics of the tachycardia may be misleading as they are more often atypical in patients after ASD repair.
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In patients with repaired ASD, both CTI-dependent and 'incisional' AFL can occur and coexist in the same patient.
“In patients with repaired ASD, both CTI-dependent and 'incisional' AFL can occur and coexist in the same patient.349”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [349]
Incisional-related AFL or IART are the most common type of SVT (75%) in ACHD patients, and occur most frequently in patients with Ebstein anomaly, Tetralogy of Fallot, single-ventricle, Fontan procedures, TGA, and atrial septal defects.
“These incisional-related AFL or intra-atrial re-entrant tachycardia (IART) are the most common type of SVT (75%) in adult congenital heart disease (ACHD) patients, and occur most frequently in patients with Ebstein anomaly, Tetralogy of Fallot, single-ventricle, Fontan procedures, transposition of the great arteries (TGA), and atrial septal defects.349,350”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [349]
Over 60% of these atrial reentry circuits involve the cavo-tricuspid isthmus.
“Over 60% of these atrial reentry circuits involve the cavo-tricuspid isthmus.349”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [349]
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- Authors
- Wasmer, K., Köbe, J., Dechering, D. G., Bittner, A., Mönnig, G., Milberg, P., Baumgartner, H., Breithardt, G., & Eckardt, L.
- Affiliations
- University Hospital Münster (DE)
- Venue
- International Journal of Cardiology
- Publisher
- Elsevier BV
- Published
- 2013-10
- Volume
- 168
- Issue
- 3
- Pages
- 2447-2452
- ISSN
- 0167-5273 (ISSN-L)
- OpenAlex
- W1997109376
- Cited by
- 46
- References
- 18
- Citations by year
- 2026: 3 · 2023: 4 · 2022: 4 · 2021: 1 · 2019: 4 · 2018: 2 · 2017: 6 · 2016: 10 · 2015: 7 · 2014: 3
- FWCI
- 4.53
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- International Journal of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Peter Osypka Foundation
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Epidemiology › Congenital Heart Disease Studies
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Cardiovascular and Diving-Related Complications
- Keywords
- right atrial flutter, atrial tachycardia, atrial septal defect repair, typical atrial flutter, ECG morphology, atrial flutter ablation, atrial fibrillation, postoperative arrhythmia
- MeSH terms
- Adult, Aged, Atrial Flutter, Female, Heart Atria, Heart Septal Defects, Atrial, Humans, Male, Middle Aged, Postoperative Complications, Prospective Studies, Tachycardia, Catheter Ablation
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