Different Clinical Courses and Predictors of Atrial Fibrillation Occurrence After Transisthmic Ablation in Patients with Preablation Lone Atrial Flutter, Coexistent Atrial Fibrillation, and Drug Induced Atrial Flutter

Long-term results of two-stage ablation approach in coexistent atrial fibrillation and typical atrial flutter: prospective randomized study

Background One of the most arrhythmias associated with atrial fibrillation (AF) is typical atrial flutter (AFL). The main methods of surgical treatment of these arrhythmias is catheter ablation. The problem of catheter ablation strategy for these coexistentarrhythmias is not solved. Purpose: To assess the effectiveness of long-term maintenance of sinus rhythm in a two-stage approach to the interventional treatment of atrial fibrillation associated with typical atrial flutter. Methods: The study included 34 patients aged 41-82 years with AF and coexistent typical AFL. Female 11 (32,35%), male 23 (67,35%). Randomization 1:1. Group 1 (n=17) has been performed radiofrequency ablation (RFA) of the cavotricuspid isthmus (CTI) with radiofrequency catheter isolation of the PV. Group 2 (n=17) has been performed only RFA of CTI. AF and AFL recurrences rate has been evaluated in both groups. Follow-up period 12 months. Results: Procedure duration and fluoroscopy time were less in group 2 that those in group 1. Extended intervention in group 1 was accompanied with complications in two cases. There were no significant differences in AF recurrence rate in both groups (p=0,43183). AFL recurrences has not been found in both groups. Conclusion: One stage ablation approach in AF patients with coexistent AFLassociated with increaseprocedure duration and fluoroscopy time. The frequency of AF recurrence in patients who underwent extended intervention (catheter isolation of the PV and RFA CTI) and in patients who underwent only the elimination of typical atrial flutter, was not statistically significantly different (p = 0.43183). In the presence of AF and typical atrial flutter, a two-stage approach to interventional treatment should be regarded as appropriate.

Differences in Stroke or Systemic Thromboembolism Readmission Risk After Hospitalization for Atrial Fibrillation and Atrial Flutter

Background

Although atrial fibrillation (AF) and atrial flutter (AFL) are different arrhythmias, they are assumed to confer the same risk of stroke and systemic thromboembolism (STE) despite a lack of available evidence. In this study, we investigated the difference in the risk of stroke or STE after AF and AFL hospitalizations.

Methodology

The National Readmission Database (NRD) 2018 was used to identify AF and AFL patients using appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and were followed until the end of the calendar year to identify stroke or STE readmissions. Survival estimates were calculated, and a Cox proportional hazards model was used to calculate the adjusted hazards ratio (aHR) and compare the risk of stroke or STE readmissions between AF and AFL groups.

Results

A total of 215,810 AF and 15,292 AFL patients were identified. AFL patients were more likely to be younger (66 vs. 70 years), male (68% vs. 47%), and had higher prevalence of obesity (25% vs. 22%), obstructive sleep apnea (14% vs. 12%), diabetes mellitus (31% vs. 26%), and alcohol use (6.9% vs. 5.5%) (all p < 0.01). After adjusting for potential patient and hospital-level characteristics, there was a statistically significant decrease in one-year stroke or STE readmission risk in AFL patients compared to AF patients (aHR 0.79 (0.66-0.95); p = 0.01).

Conclusions

AFL patients are commonly younger males with a higher burden of medical comorbidity. There is a decrease in the one-year risk of stroke or STE events in AFL patients compared to AF. The predictors of stroke and STE are similar in both AFL and AF groups. Further studies with longer follow-up and anticoagulation data are needed to verify the results.

Implantable loop recorder for augmenting detection of new-onset atrial fibrillation after typical atrial flutter ablation

Background

Patients with typical atrial flutter (AFL) undergoing successful cavotricuspid isthmus ablation remain at risk for future development of new-onset atrial fibrillation (AF). Conventional monitoring (CM) techniques have shown AF incidence rates of 18%–50% in these patients.

Objectives

To evaluate whether continuous monitoring using implantable loop recorders (ILRs) would enhance AF detection in this patient population.

Methods

Veteran patients undergoing AFL ablation between 2002 and 2019 who completed at least 6 months of follow-up after the ablation procedure were included. We compared new-onset AF detection between those who underwent CM and those who received ILRs immediately following AFL ablation.

Results

A total of 217 patients (age: 66 ± 9 years; all male) participated. CM was used in 172 (79%) and ILR in 45 (21%) patients. Median follow-up duration after ablation was 4.1 years. Seventy-nine patients (36%) developed new-onset AF, which was detected by CM in 51 and ILR in 28 (30% vs 62%, respectively, P < .001). AF detection occurred at 7.7 months (IQR: 4.7–17.5) after AFL ablation in the ILR group vs 41 months (IQR: 23–72) in the CM group (P < .001). Eleven patients (5%) experienced cerebrovascular events (all in the CM group) and only 4 of these patients (36%) were on long-term anticoagulation.

Conclusion

Patients undergoing AFL ablation remain at an increased risk of developing new-onset AF, which is detected sooner and more frequently by ILR than by CM. Improving AF detection may allow optimization of rhythm management strategies and anticoagulation in this patient population.

The clinical outcomes of patients who developed typical atrial flutter on class 1C anti arrhythmic medications treated with hybrid approach

Introduction

A common approach to patients, who developed atrial flutter secondary to treatment with class 1C anti‐arrhythmic drugs for atrial fibrillation (AF) (1C flutter), is a hybrid approach: ablation of the Cavo‐Tricuspid isthmus (CTI) and continuation 1C medical treatment to prevent recurrence of AF. We aim to explore the clinical outcome of patients treated in this approach.

Methods and Results

Two hundred and four consecutive patients who underwent ablation for typical AFL at a tertiary medical center between 2010 and 2016 were enrolled and followed up. The clinical outcome of patient treated by the hybrid approach (treatment group; n = 67) was compared to patient without history of AF (control group; n = 137). The primary endpoint was time to occurrence of AF. Twenty‐eight (41.8%) patients in treatment group had AF occurrence in 1 year, including 9 (13.4%) patients who needed to escalate anti‐arrhythmic drug treatment to class III, and 11 (16.4%) patients who underwent AF ablation. In comparison, only 21 (15.3%) patients in control group had occurrence during the first year after ablation. The median time from ablations till AF occur was 106 ± 481 days in treatment group, and 403 ± 668 days in control group (P < .01).

Conclusions

There is a relatively high rate of AF recurrence in patients treated with the hybrid approach during the first year after CTI ablation. An alternative approach should be considered in this selected population.

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

Background

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.

Aim

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).

Methods

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.

Results

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.

Conclusion

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.

Administration of antiarrhythmic drugs to maintain sinus rhythm after catheter ablation for atrial fibrillation: a meta-analysis

BACKGROUND

Whether the short-term administration of antiarrhythmic drugs (AADs) to maintain sinus rhythm following catheter ablation (CA) for atrial fibrillation (AF) can prevent the recurrence of AF is still a matter of debate. We searched the PubMed database and the Cochrane Library, and compiled a list of retrieved articles. We included only randomised controlled trials(RCTs) that compared any AADs against control (placebo or no treatment) or other AADs following CA for AF. Statistical analysis of the odds ratio (OR) and corresponding 95% confidence interval (CI) were used to determine the overall effect of both outcomes. The Mantel-Haenszel method was used to pool data of the outcomes of AF recurrence into fixed effect model meta-analyses.

AIMS

We performed a systematic review to determine the effectiveness of short-term treatment with AADs on the recurrence of AF after CA.

RESULTS

Six RCTs were included in this study, with a total of 814 patients. Post-procedural temporary administration of AADs in patients after CA for AF reduced the early recurrence of AF (antiarrhythmic drug 103 patients [25.3%], control 162 patients [39.8%]; OR 0.47 [95% CI 0.34-0.64]; χ(2)  = 3.77; P = 0.58; I(2)  = 0%). No significant difference in patients after CA for AF in the late recurrence of AF (antiarrhythmic drug 148 patients [36.5%], control 171 patients [42.5%]; OR 0.77 [95% CI 0.57-1.03]; χ(2)  = 3.15; P = 0.68; I(2)  = 0%). The heterogeneity was zero in both analyses.

CONCLUSION

Although the continued administration of AADs after CA for AF can decrease early atrial tachycardias (ATa), this treatment does not prevent late ATa.

Risk and outcome after ablation of isthmus-dependent atrial flutter in elderly patients

Purpose of the research

To study the influence of age on the clinical presentation and long-term outcome of patients referred for atrial flutter (AFL) ablation. Age-related differences have been reported regarding the prognosis of arrhythmias.

Methods

A total of 1187 patients with a mean age 65±12 years consecutively referred for AFL ablation were retrospectively analyzed in the study.

Results

445 (37.5%) patients were aged ≥70 (range 70 to 93) among which 345 were aged 70 to 79 years (29.1%) and 100 were aged ≥80 (8.4%). In multivariable analysis, AFL-related rhythmic cardiomyopathy and presentation with 1/1 AFL were less frequent (respectively adjusted OR = 0.44, 0.27–0.74, p = 0.002 and adjusted OR = 0.29, 0.16–0.52, p<0.0001). AFL ablation-related major complications were more frequent in patients ≥70 although remained lower than 10% (7.4% in ≥70 vs. 4.2% in <70, adjusted OR = 1.74, 1.04–2.89, p = 0.03). After 2.1±2.7 years, AFL recurrence was less frequent in patients ≥70 (adjusted OR = 0.54, 0.37–0.80, p = 0.002) whereas atrial fibrillation (AF) occurrence was as frequent in the 70–79 and ≥80 age subsets. As expected, cardiac mortality was higher in older patients. Patients aged ≥80 also had a low probability of AFL recurrence (5.0%) and AF onset (19.0%).

Conclusions

Older patients represent 37.5% of patients referred for AFL ablation and displayed a <10% risk of ablation-related complications. Importantly, AFL recurrences were less frequent in patients ≥70 while AF occurrence was as frequent as in patients <70. Similar observations were made in patients ≥80 years. AFL ablation appears to be safe and efficient and should not be ruled out in elderly patients.

Long term outcome of cavotricuspid isthmus cryoablation for the treatment of common atrial flutter in 180 patients: a single center experience

OBJECTIVE

Recent literature has shown that common type atrial flutter (AFL) can recur late after cavotricuspid isthmus (CTI) catheter ablation using radiofrequency energy (RF). We report the long term outcome of a large group of patients undergoing CTI ablation using cryothermy for AFL in a single center.

METHODS

Patients with AFL referred for CTI ablation were recruited prospectively from July 2001 to July 2006. Cryoablation was performed using a deflectable, 10.5 F, 6.5 mm tip catheter. CTI block was reassessed 30 min after the last application during isoproterenol infusion. Recurrences were evaluated by 12-lead ECG and 24 h Holter recording every clinic visit (1/3/6/9 and 12 months after the procedure and yearly thereafter) or if symptoms developed.

RESULTS

The 180 enrolled patients had the following characteristics: 39 women (22%), mean age 58 years, no structural heart disease in 86 patients (48%), mean left atrium diameter 44+/-7 mm and mean left ventricular ejection fraction 57+/-7%. The average number of applications per patient was 7 (3 to 20) with a mean temperature and duration of -88 degrees C and 3 min, respectively. Acute success was achieved in 95% (171) of the patients. There were no complications. After a mean follow-up of 27+/-17 (from 12 to 60) months, the chronic success rate was 91%. The majority of the recurrences occurred within the first year post ablation. One hundred and twenty three patients had a history of atrial fibrillation (AF) prior to CTI ablation and 85 (69%) of those remained having AF after cryoablation. In 20 of 57 (35%) patients without a history of AF prior to CTI ablation, AF occurred during follow-up.

CONCLUSIONS

This prospective study showed a 91% chronic success rate (range 12 to 60 months) for cryoablation of the CTI in patients with common type AFL and ratified the frequent association of AF with AFL.

Atrial fibrillation is common after ablation of isolated atrial flutter during long-term follow-up

BACKGROUND

Previous studies have shown that the incidence of atrial fibrillation after atrial flutter ablation is approximately 20% among patients presenting with typical atrial flutter and no history of fibrillation. However, studies involving this population have been small, with follow-up typically less than 2 years.

OBJECTIVE

The purpose of this study was to provide a more accurate perspective on the long-term risk of atrial fibrillation in patients presenting with isolated typical flutter.

METHODS

Clinical records of consecutive patients who had flutter ablations at Presbyterian Medical Center between 1999 and 2004 were assessed (n = 254). Patients with no apparent history of atrial fibrillation before their flutter ablation were identified. Retrospective follow-up data on these patients were obtained by review of medical records from our institution, from patients' cardiologists and primary care physicians, and by direct patient questionnaires. Postablation atrial fibrillation and other arrhythmias were identified by electrocardiography, Holter monitoring, and subsequent clinical records.

RESULTS

Postablation atrial fibrillation was identified in 40 (50%) of 80 patients, and an additional three patients presented with atypical atrial flutter, after a mean follow-up of 29.6 +/- 21.7 months. The incidence of atrial fibrillation was progressive, with 49% occurring after 2 years. There was no difference in age, left atrial size, hypertension, structural heart disease, or left ventricular dysfunction in patients who developed atrial fibrillation compared with those who did not.

CONCLUSION

Atrial fibrillation occurs in over half of patients who present with isolated typical flutter after cavotricuspid isthmus ablation. Asymptomatic patients should be screened for recurrent arrhythmias indefinitely after ablation. In certain patients, atrial fibrillation and flutter may be different expressions of the same electrical disease, and eradication of the flutter circuit will not prevent the eventual manifestation of atrial fibrillation.

Can atrial fibrillation with a coarse electrocardiographic appearance be treated with catheter ablation of the tricuspid valve-inferior vena cava isthmus? Results of a multicentre randomised controlled trial

OBJECTIVE

To see if strategy of ablating the tricuspid annulus-inferior vena cava isthmus (TV-IVC) is superior to electrical cardioversion to prevent recurrences in patients with coarse atrial fibrillation.

DESIGN

Prospective randomised controlled multicentre study.

SETTING

Four tertiary referral hospitals in the UK.

PATIENTS

57 patients with persistent coarse atrial fibrillation (irregular P waves > or =0.15 mV in > or =1 ECG lead).

INTERVENTIONS

Patients were randomised to receive external cardioversion (group A, n = 30) or TV-IVC ablation +/- DC cardioversion (group B, n = 27).

MAIN OUTCOME MEASURES

Cardiac rhythm, scores on quality of life and symptom questionnaires were assessed at 4, 16 and 52 weeks after the procedure.

RESULTS

20 (67%) patients in group A and 19 (70%) patients in group B were in sinus rhythm immediately after their index procedure. At 4, 16 and 52 weeks, the number of patients in sinus rhythm were 5, 3 and 2 in group A and 3, 3 and 1 in group B (p = NS). The quality of life and symptom questionnaire scores were similar in the two groups at each period of follow-up, although they were significantly better for sinus rhythm than for atrial fibrillation at each follow-up visit.

CONCLUSIONS

As a first-line strategy, TV-IVC ablation offers no advantages over direct current cardioversion for the management of coarse atrial fibrillation.

Common atrial flutter and atrial fibrillation are not always two stages of the same disease. A long-term follow-up study in patients with atrial flutter treated with cavo–tricuspid isthmus ablation

OBJECTIVE

Both atrial flutter and atrial fibrillation (AF) frequently develop in the same patient. There is therefore reasonable doubt that flutter ablation may not solve the clinical problem, owing to the occurrence/recurrence of AF. The aim of this study was to establish whether cavo-tricuspid isthmus ablation is curative in patients with common atrial flutter alone or combined with AF.

METHODS

One hundred and forty-one patients (114 male, 27 female, mean age 63 +/- 10 years) who had cavo-tricuspid isthmus ablation were followed up for 44 +/- 20 months. Before ablation, 48 patients had only atrial flutter (group A), whereas 93 patients had both atrial flutter and AF. Among the latter, during antiarrhythmic therapy, 31 patients had only atrial flutter (group B1), whereas 62 patients (group B2) continued to experience both arrhythmias.

RESULTS

During follow-up, 27% of group A and 61% of group B patients had documented recurrent AF (P < 0.001). AF recurred in 51% of group B1 and in 66% of group B2 patients (P = NS). Permanent AF occurred in 6% of group A, 3% of group B1 and 21% of group B2 (P < 0.01). Specific symptom scale scores significantly decreased in all groups, particularly in group A. Two patients of group B had cerebral ischaemic attacks.

CONCLUSIONS

Over a long-term follow-up, cavo-tricuspid isthmus ablation is curative in >70% of patients with atrial flutter alone. Therefore, if no AF is documented, more extensive ablation is not needed. By contrast, cavo-tricuspid isthmus ablation is frequently unable to prevent AF in patients with both atrial flutter and AF, although in some cases a significant clinical benefit may be obtained.