Prognostic value of atrial fibrillation inducibility after right atrial flutter ablation

Concomitant pulmonary vein isolation for induced atrial fibrillation to reduce future risk of atrial fibrillation after ablation for isolated atrial flutter

BACKGROUND

A significant proportion of patients with isolated atrial flutter will have atrial fibrillation (AF) after cavotricuspid isthmus (CTI) ablation.

OBJECTIVE

The aim of this study was to determine whether concomitant pulmonary vein isolation (PVI) could reduce the incidence of new-onset AF (NOAF) in the setting of inducible AF after CTI ablation.

METHODS

A total of 275 consecutive patients with isolated atrial flutter who successfully underwent CTI ablation were included. Patients were stratified into the induced AF group (55 patients) and the noninduced AF group (220 patients) on the basis of the inducibility of AF. Subsequently, the induced AF group was randomly divided into a PVI group (28 patients) and non-PVI (27 patients) group.

RESULTS

During 27.0 ± 6.0 months of follow-up, the PVI group (7.1% vs 51.9% [P < .001]; hazard ratio [HR], 0.103 [95% confidence interval for HR, 0.038-0.278; P < .001]) and noninduced AF group (13.2% vs 51.9% [P < .001]); HR, 0.207 [95% confidence interval for HR, 0.073-0.586; P < .001]) exhibited substantially lower incidence and risk of NOAF compared with the non-PVI group. Kaplan-Meier analysis showed that history of hypertension, cardiovascular disease, and heart failure and larger body mass index, larger left atrial diameter, and lower left ventricular ejection fraction were identified predictors of NOAF.

CONCLUSION

Inducibility of AF during CTI ablation is positively associated with an increased risk of NOAF, whereas concomitant PVI for induced AF can significantly reduce the incidence of NOAF.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Risk of New-Onset Atrial Fibrillation Post-cavotricuspid Isthmus Ablation in Typical Atrial Flutter Without History of Atrial Fibrillation

Aims: The aim was to describe the incidence of atrial fibrillation (AF) after cavotricuspid isthmus (CTI) ablation in patients with typical atrial flutter (AFL) without history of AF and to identify risk factors for new-onset AF after the procedure.

Methods: A total of 191 patients with typical AFL undergoing successful CTI ablation were enrolled. Patients who had history of AF, structural heart disease, cardiac surgery, or ablation or who received antiarrhythmic drug after procedure were excluded. Clinical and electrophysiological data were collected.

Results: There were 47 patients (24.6%) developing new AF during a follow-up of 3.3 ± 1.9 years after CTI ablation. Receiver operating characteristic (ROC) curves indicated that the cut-off values of left atrial diameter (LAD) and CHA₂DS₂-VASc score were 42 mm and 2, with area under the curve of 0.781 and 0.550, respectively. The multivariable Cox regression analysis revealed that obstructive sleep apnea (OSA) [hazard ratio (HR) 3.734, 95% confidence interval (CI) 1.470–9.484, P = 0.006], advanced interatrial block (aIAB) (HR 2.034, 95% CI 1.017–4.067, P = 0.045), LAD > 42 mm (HR 2.710, 95% CI 1.478–4.969, P = 0.001), and CHA₂DS₂-VASc score > 2 (HR 2.123, 95% CI 1.118–4.034, P = 0.021) were independent risk factors of new-onset AF.

Conclusion: A combination of OSA, aIAB, LAD > 42 mm, and CHA₂DS₂-VASc > 2 was a strongly high risk for new-onset AF after ablation for typical AFL, and it had significance in postablation management in clinical practice.

CHA2DS2-VASc Score as a Predictor of New-Onset Atrial Fibrillation After Catheter Ablation of Typical Atrial Flutter

Purpose

Cavotricuspid isthmus (CTI) ablation is an effective procedure for typical atrial flutter (AFL), but patients remain at an elevated risk for developing new atrial fibrillation (AF). Currently, there are limited data on the utility of CHA₂DS₂-VASc score to predict new-onset AF after typical AFL ablation. In this study, we assessed whether the CHA₂DS₂-VASc score is a useful predictor of new-onset AF after CTI ablation in typical AFL patients without a prior history of AF.

Methods

This was a retrospective study of 103 typical AFL patients with no prior history of AF, who underwent successful CTI ablation. The endpoint was occurrence of new-onset AF during follow-up.

Results

During a mean follow-up period of 24.6 ± 16.9 months, at least one episode of AF occurred in 33 (32%) patients. Multivariate Cox regression analysis revealed that CHA₂DS₂-VASc score (hazard ratio = 1.736; 95% confidence interval = 1.370–2.201; P < 0.001) was significantly associated with postablation new-onset AF (area under the curve = 0.797). A cutoff value of three stratified these patients into two groups with different incidences of postablation new-onset AF (67.9 vs. 18.7%, P < 0.001).

Conclusion

The CHA₂DS₂-VASc score is a useful tool for the prediction of new-onset AF after ablation of typical AFL. Patients with CHA₂DS₂-VASc score ≥3 are more likely to develop new-onset AF and should be monitored more closely.

Prophylactic pulmonary vein isolation during cavotricuspid isthmus ablation for atrial flutter: A meta-analysis

BACKGROUND

Atrial arrhythmias (AA), including atrial fibrillation (AF), have been reported in patients after cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFL). Several studies have examined the effect of performing concomitant pulmonary vein isolation (PVI) with CTI on recurrent AA. These studies were analyzed to determine the overall effect of this approach on recurrent AA.

METHODS

PubMed and Google Scholar were searched for randomized trials comparing the incidence of AA after CTI versus CTI + PVI until June 2018. Only patients without prior history of AF were included in the recurrent AA analysis. All patients were included in the analyses of other clinical outcomes.

RESULTS

Four randomized control trials were included in the meta-analysis. In the recurrent AA analysis, a total of 314 patients were randomized in the studies (n = 158 CTI, n = 156 CTI + PVI). Freedom from AA at 1 year was significantly higher in the CTI + PVI group versus CTI alone (odds ratio [OR] 0.25 [0.14, 0.44] 95% confidence interval [CI], P < 0.00001). A total of 550 patients (n = 336 CTI, n = 214 CTI + PVI) were included in analyses for procedure time, fluoroscopy time, and complications rates. Procedure time and fluoroscopy time were significantly longer in the CTI + PVI group (mean difference [MD]: 103.31 min [94.40, 112.23] 95% CI, P < 0.00001) and (MD: 16.47 min [14.89, 18.05] 95% CI, P < 0.00001), respectively. Total complications were statistically similar between groups.

CONCLUSION

This meta-analysis shows addition of a prophylactic PVI during CTI ablation significantly reduces recurrent AA at 1 year without significantly increasing major complications.

Is HATCH score a reliable predictor of atrial fibrillation after cavotricuspid isthmus ablation for typical atrial flutter?

OBJECTIVE

We determined the effectiveness of the HATCH score in patients with typical atrial flutter (AFl) undergoing cavotricuspid isthmus (CTI) ablation to predict long-term atrial fibrillation (AF).

METHODS

We conducted an observational retrospective single-center cohort study including all patients admitted to our hospital for a CTI ablation between 1998 and 2010. The patients were divided into four categories: 1) new-onset AF (no prior AF and AF during follow-up (FU)); 2) old AF (prior AF and no AF during FU); 3) prior and post AF (AF prior and post CTI ablation); and 4) no AF.

RESULTS

Four hundred and eight patients were included. In patients without prior AF, the hazard ratio (HR) for new-onset AF during FU was 0.98 (CI 95%: 0.65-1.50; p = 0.95) and 1.00 (CI 95%: 0.57-1.77; p = 0.98) for HATCH ≥ 2 and HATCH ≥ 3, respectively. In patients with prior AF, the HR for AF was 1.41 (CI 95%: 0.87-2.28; p = 0.17) and 1.79 (CI 95%: 0.96-3.35; p = 0.06), for HATCH ≥ 2 and HATCH ≥ 3, respectively. Left atrial enlargement was positively correlated with the occurrence of AF during FU, especially in the subgroup without prior AF, which had a HR of 2.44 (CI 95%: 1.35-4.40; p = 0.003), a HR of 2.88 (CI 95%: 1.36-6.10; p = 0.006) and a HR of 3.68 (CI 95%: 1.71-7.94; p = 0.001), for slight, moderate and severely dilated left atrial dimension, respectively, compared with a normal value.

CONCLUSIONS

HATCH score did not predict AF in patients with typical AFl who underwent CTI ablation. Basal left atrium dimension could help predict new-onset AF.