Predictors of the presence of typical atrial flutter in patients undergoing atrial fibrillation ablation

Background

Typical cavotricuspid isthmus (CTI) dependent atrial flutter (Afl) may develop spontaneously in patients undergoing atrial fibrillation (AF) ablation and it is also responsible for a significant portion of recurrences after AF ablation. In this situation, the second ablation for typical Afl is frequently needed. If the predictors of typical Afl can be known in such patients, CTI ablation for typical Afl can also be performed in the same session as AF ablation. Thus, the risks and increased costs of the second ablation procedure can be avoided. There is insufficient data related to the predictors of typical Afl in patients undergoing AF ablation.

Purpose

In this study, we aimed to investigate the predictors of typical Afl in patients undergoing catheter ablation for AF.

Methods

In this retrospective study, we consecutively enrolled 135 patients with AF undergoing index catheter ablation. Patients who did not come regular follow-up after ablation were excluded. Thus, 131 patients were included. The patients were divided two groups according to spontaneous typical Afl development before or after AF ablation. They were compared in terms of baseline characteristics and procedural features.

Results

The mean age of the patients was 58 (48–62), 65 of them (49.6%) were male, typical Afl was observed in 20 patients (15.2%). The frequency of male gender was higher (80.0% vs 44.1%, p=0.003), the left ventricular (LV) ejection fraction was lower (56.2±10.9% vs 60.7±6.7%, p=0.015), LV end-diastolic diameter was higher [50.0 (48.2–53.0) vs 47.0 (44.0–49.0), p<0.001), the left atrium diameter was higher (41.4±4.5 vs 38.4±4.5, p=0.008), and the right atrium (RA) diameter was higher (41.6±3.5 vs 36.8±3.7, p<0.001) in patients with typical Afl than in those without it (Figure 1a). Laboratory measurements, drug use, and procedural characteristics were similar between groups. A logistic regression analysis demonstrated that male gender [OR: 4.5, 95% CI: 1.01–20.03, p=0.048) and the RA diameter [OR: 1.57, 95% CI: 1.22–2.02, p<0.001] were independent predictors of the presence of typical Afl (Figure 1b). A Receiver Operating Characteristic curve showed that optimal cut-off value of the RA diameter to predict the presence of typical atrial flutter was 40.5 mm (AUC: 0.843, sensitivity %80, specificity %85, p<0.001) (Figure 2).

Conclusion

A RA diameter greater than 40.5 mm may predict the presence of spontaneous typical Afl in patients undergoing catheter ablation for AF. This information can help to identify patients who would benefit from CTI ablation in the same session as AF ablation.

Funding Acknowledgement

Type of funding sources: None.

The mitral inflow E/A ratio before the procedure may predict late recurrence after pulmonary vein isolation using second-generation cryoballoon

Funding Acknowledgements

Type of funding sources: None.

Background

The left ventricular (LV) diastolic dysfunction (DD) increases the risk of atrial fibrillation (AF) development. Some studies investigated whether a relationship between DD and late recurrence after catheter ablation for AF, but they found conflictory results. Such studies had relatively short follow-up duration and they did not have a standard ablation protocol. Some patients were taken to PVI only, while additional linear lesions in localizations such as the left atrial (LA) roof, LA isthmus, and cavotricuspid isthmus were added in others.

Purpose

The mitral inflow E/A ratio is a simple and practical method commonly used to evaluate LV DD. We aimed to investigate whether the E/A ratio before the procedure was predictive for late recurrence in patients with AF undergoing pulmonary vein isolation (PVI) with cryoballoon (CB).

Methods

A total of 100 patients undergoing AF ablation for the first time using second-generation CB were included. Only patients with paroxysmal AF and sinus rhythm the day before the procedure, and with pre-procedural pro-B natriuretic peptide levels within normal limits were included. The patients with and without late recurrence were compared in terms of basal characteristics and procedural features. Any atrial tachyarrhythmia episode longer than 30 s after the blanking period was defined as late recurrence.

Results

The patients [age: 58.0 (50.2-62.0) years, 53 female] were followed up for a median of 44.5 (14.2-62.7) months and late recurrence developed in 25 patients. Female gender (72.0% vs 46.7%), hypertension (72.0% vs 48.0%), and the frequency of early recurrence (20.0% vs 4.0%) were found to be higher in patients with late recurrence than in those without it (p =0.028, 0.037 and 0.022, respectively). The CHA2DS2-Vasc score was higher [2.0 (1.0-3.0) vs 1.0 (0-2.0)], AF duration was longer (27.8 ± 9.4 vs 22.0 ± 8.4 months) and the E/A ratio was lower [0.5 (0.4-1.2) vs 1.4 (0.6-1.7)] in patients with late recurrence than in those without it (p=0.014, 0.006 and 0.001, respectively) (Figure 1). The groups were similar in terms of precedural features. A multivariate analysis showed that female gender (HR: 4.46, 95%CI: 1.24-15.97, p=0.021), early recurrence (HR: 10.22, 95% CI: 2.49-41.99, p=0.001), and E/A ratio (HR: 0.25, 95%CI: 0.11-0.57, p=0.001) were independent predictors for late recurrence (Figure 2). Receiver operating characteristic analysis showed that the optimal cut-off level of the E/A ratio was 0.84. Any ATa free survival rate was significantly lower in patients with E/A ratio <0.84 than in those with ≥0.84 (56.1% vs 88.1%, log-rank p<0.001).

Conclusions

Female gender, early recurrence, and E/A ratio are independent predictors of late recurrence in patients with AF undergoing PVI using second-generation CB. Measuring the E/A ratio in patients with sinus rhythm before AF ablation may help to predict future recurrences.