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Johner N, Namdar M, Shah DC. Atypical Atrial Flutter: Electrophysiological Characterization and Effective Catheter Ablation. J Cardiovasc Electrophysiol 2025. [PMID: 39821917 DOI: 10.1111/jce.16543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2024] [Revised: 11/29/2024] [Accepted: 12/03/2024] [Indexed: 01/19/2025]
Abstract
Atrial flutter (AFL), defined as macro-re-entrant atrial tachycardia, is associated with debilitating symptoms, stroke, heart failure, and increased mortality. AFL is classified into typical, or cavotricuspid isthmus (CTI)-dependent, and atypical, or non-CTI-dependent. Atypical AFL is a heterogenous group of re-entrant atrial tachycardias that most commonly occur in patients with prior heart surgery or catheter ablation. The ECG pattern is poorly predictive of circuit anatomy but may still provide mechanistic insight. AFL is difficult to manage medically and catheter ablation is the preferred treatment for most patients. Recent progress in technology and clinical electrophysiology has led to detailed characterization of re-entry circuits and effective ablation strategies. Combined activation and entrainment mapping are key to identifying the re-entry circuit. The presence of a slow-conducting isthmus, localized re-entry, dual-loop re-entry or bystander loops may lead to misleading activation maps but can be identified by electrogram examination and entrainment mapping. In the occasional patient without inducible AFL, substrate mapping in sinus rhythm may be a viable strategy. Long-term ablation success requires the creation of a transmural continuous lesion across a critical component of the re-entry circuit. Procedural endpoints include bidirectional conduction block across linear lesions and non-inducibility of atrial tachycardia. The present review discusses the epidemiology, mechanisms, ECG characteristics, electrophysiological characterization, and catheter ablation of atypical AFL.
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Affiliation(s)
- Nicolas Johner
- Division of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Mehdi Namdar
- Division of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Dipen C Shah
- Division of Cardiology, Geneva University Hospitals, Geneva, Switzerland
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Garcia-Montero M, Khairy P. An unusual response to entrainment mapping in a patient with congenital heart disease. Heart Rhythm 2024; 21:1428-1430. [PMID: 38490599 DOI: 10.1016/j.hrthm.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 03/17/2024]
Affiliation(s)
- Marta Garcia-Montero
- From the Electrophysiology Service and Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Paul Khairy
- From the Electrophysiology Service and Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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Zhang A, Ding L, Zhang H, Mi L, Yu F, Tang M. Radiofrequency catheter ablation for pulmonary hypertension patients with atrial flutter. ESC Heart Fail 2024; 11:883-892. [PMID: 38200382 DOI: 10.1002/ehf2.14659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/06/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
AIMS We aimed to evaluate the effects of radiofrequency catheter ablation (RFCA) and the factors influencing mortality after RFCA in patients with pulmonary hypertension (PH) and atrial flutter (AFL). METHODS AND RESULTS Fifty-eight consecutive PH patients with AFL who underwent an electrophysiological study and RFCA between April 2013 and August 2021 were selected for this study. In the study population, pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) was the most common type of PH (n = 34, 59%), followed by idiopathic pulmonary arterial hypertension (IPAH) (n = 19, 33%). Typical atrial flutter was the most common type of atrial flutter (n = 50, 86.2%). Sinus rhythm was restored in 53 (91.4%) patients during RFCA. After a mean follow-up of 33.8 months, AFL recurred in a total of 22 patients. Nine of them underwent repeat RFCA, and the site of the repeat ablation was not exactly the same as the first. At a median follow-up of 34.6 months after the last ablation, none of the patients who underwent repeat RFCA experienced AFL recurrence, and all of these patients survived. There were no procedure-related complications during hospitalization or follow-up. Univariate Cox regression analysis suggested that AFL recurrence after the last ablation was not associated with all-cause mortality. NT-proBNP (HR: 1.00024, 95% CI: 1.00008-1.00041, P = 0.004), pulmonary artery systolic pressure (PASP) (HR: 1.048, 95% CI: 1.020-1.076, P = 0.001), and IPAH (vs. PAH-CHD, HR 7.720, 95% CI: 1.437-41.483, P = 0.017) were independent predictors of all-cause mortality in PH patients with AFL after RFCA. Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) of PASP for predicting all-cause mortality was 0.708. There was no significant difference in the Kaplan-Meier curves for all-cause mortality between patients with AFL recurrence after the last ablation and those without recurrence (P = 0.851). Patients with higher PASP (≥110 mmHg) and IPAH showed the lower survival rate in Kaplan-Meier curves. CONCLUSION Repeat ablation was safe and feasible in patients with recurrent AFL and can maintain sinus rhythm. AFL recurrence was not associated with all-cause mortality, and patients with high PASP or IPAH were at higher risk for adverse outcomes.
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Affiliation(s)
- Aikai Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lei Ding
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Hongda Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lijie Mi
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Fengyuan Yu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Min Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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