Catheter ablation of scar-related atypical atrial flutter
Open accessAbstract
AIMS: The aim of the study was to assess the impact of isthmus location of atypical atrial flutters/atrial tachycardias (ATs) on outcomes of catheter ablation. Atrial tachycardias are clinically challenging arrhythmias that can occur in the presence of atrial scar--often due to either cardiac surgery or prior ablation for atrial fibrillation. We previously demonstrated a catheter ablation approach employing rapid multielectrode activation mapping with targeted entrainment manoeuvrs. However, the role that AT isthmus location plays in acute and long-term success of ablation remains uncertain. METHODS AND RESULTS: Retrospective multicenter analysis of 91 consecutive AT patients undergoing ablation using a systematic four-step approach: (i) high-density activation mapping; (ii) analysis of atrial activation to identify wavefronts of electrical propagation; (iii) targeted entrainment of putative channels; and (iv) irrigated radiofrequency ablation of constrained regions of the circuit. Clinical outcomes, procedural details, and clinical profiles were determined. A total of 171 ATs (1.9 ± 1.0 per patient, 26% septal ATs) were targeted for ablation. The acute success rates were 97 and 77% for patients with either non-septal ATs or septal ATs, respectively (P = 0.0023). Similarly, the long-term success rates were 82 and 67% for patients with either no septal ATs or at least one septal AT, respectively (P = 0.1057). The long-term success rates were 75, 88, and 57% for patients with ATs associated with prior catheter ablation, cardiac surgery or MAZE, and idiopathic atrial scar, respectively. CONCLUSION: Catheter ablation of AT can be successfully performed employing a strategy of combined high-density activation and entrainment mapping. Septal ATs are associated with higher rates of acute and long-term recurrences.
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In scar-related areas of block, the ECG pattern may not be typical, and conversely a typical AFL ECG may be produced by atypical MRT even due to LA circuits.
“In these cases with scar-related areas of block the ECG pattern may not Table 12 Therapy of atrial flutter/ macro-reentrant tachycardia Recommendation Reference Acute therapy Synchronised DC cardioversion is recommended for haemodynamically unstable patients with AFL/MRT a 131,132 IV anticoagulation may be considered in case emergency cardioversion is necessary.Anticoagulation should be continued”
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 [160]
Multiple circuits are possible in AFL, including CTI-dependent AFL which remains the most common type even after surgery or ablation.
“Multiple circuits are possible, including CTI-dependent AFL which still is the most common type even in these situations.11,159,160”
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 [160]
The superior transseptal surgical approach to mitral valve repair or replacement is more arrhythmogenic than direct posterior left atrial atriotomy, leading to macroreentrant tachycardia circuits involving both atria that are difficult to eliminate by ablation.
“The superior transseptal surgical approach to mitral valve repair or replacement is more arrhythmogenic than direct posterior LA atriotomy, leading to the appearance of MRT circuits involving both atria, and that are difficult to eliminate by ablation.160,200”
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 [160]
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Atrial flutter: more than just one of a kind
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- Authors
- Coffey, J. O., d'Avila, A., Dukkipati, S., Danik, S. B., Gangireddy, S. R., Koruth, J. S., Miller, M. A., Sager, S. J., Eggert, C. A., & Reddy, V. Y.
- Affiliations
- Icahn School of Medicine at Mount Sinai (US)
- Harvard University (US)
- University of Miami (US)
- St. Jude Medical (United States) (US)
- Corresponding author
- Reddy, Vivek Y.
- Venue
- EP Europace
- Publisher
- Oxford University Press (OUP)
- Published
- 2013-02-05
- Volume
- 15
- Issue
- 3
- Pages
- 414-419
- ISSN
- 1099-5129 (ISSN-L)
- 1532-2092
- OpenAlex
- W2145820903
- Cited by
- 95
- References
- 18
- Citations by year
- 2026: 3 · 2025: 5 · 2024: 4 · 2023: 9 · 2022: 6 · 2021: 11 · 2020: 11 · 2019: 7 · 2018: 8 · 2017: 8 · 2016: 6 · 2015: 8 · 2014: 6 · 2013: 2
- FWCI
- 4.93
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- EP Europace (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Keywords
- atypical atrial flutter, atrial tachycardia, catheter ablation, atrial scar, irrigated radiofrequency ablation, atrial fibrillation surgery, maze procedure, long-term recurrence
- MeSH terms
- Adult, Aged, Aged, 80 and over, Atrial Flutter, Cicatrix, Female, Humans, Male, Middle Aged, Recurrence, Retrospective Studies, Risk Factors, Tachycardia, Supraventricular, Time Factors, United States, Logistic Models, Proportional Hazards Models, Odds Ratio, Treatment Outcome, Catheter Ablation, Electrophysiologic Techniques, Cardiac, Kaplan-Meier Estimate, Young Adult
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