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CLINICAL RESEARCH: ELECTROPHYSIOLOGY

Importance of ablating all potential right atrial flutter circuits in postcardiac surgery patients

^* Department of Cardiology, Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA

Manuscript received January 12, 2004; revised manuscript received April 13, 2004, accepted April 18, 2004.

^* Reprint requests and correspondence: Dr. Nassir F. Marrouche, Section of Cardiac Electrophysiology, Department of Cardiology/Desk F15, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA.
marroun{at}ccf.org

OBJECTIVES: In patients with atrial flutter (AFL) and postoperative right atrial incisional scars, we sought to assess if the use of additional ablative lesions that targeted all potential re-entrant circuits, regardless of the presenting type of flutter, would prevent long-term recurrence.

BACKGROUND: Patients with AFL and incisional scars have a complex atrial substrate that may promote multiple mechanisms of intra-atrial re-entry.

METHODS: Twenty-nine patients with single right atrial incisional scars undergoing ablation for scar-dependent (n = 15) and cavotricuspid isthmus (CTI)-dependent (n = 14) flutter were studied.

RESULTS: In the scar-dependent group, 9 of 15 (60%) patients had inducible or spontaneous CTI-dependent flutter immediately after ablation. In the group with CTI flutter, 7 of 14 (50%) patients had scar-related flutter immediately after ablation. If a second type of flutter was found during the initial ablation, a second ablation was performed either along the isthmus (scar-dependent group) or from the scar to another anatomic boundary (isthmus-dependent group). Patients were followed for 24 ± 5 months and 18 ± 6 months in the scar- and CTI-dependent groups, respectively. In the scar-dependent group, five of six (83%) who underwent only a single flutter line had recurrence at 3 ± 1 months. In the isthmus-dependent group, three of seven (42%) patients who had only one flutter line performed had recurrence at 5 ± 3 months. There was no flutter recurrence in patients who initially received two different flutter lines or in patients who subsequently underwent a second flutter line at follow-up.

CONCLUSIONS: In patients with postoperative right atrial incisional scar and flutter, multiple ablation lines that target both scar-related and classic isthmuses appear necessary to prevent long-term recurrence.

Abbreviations and Acronyms   AFL = atrial flutter   CPB = cardiopulmonary bypass   CS = coronary sinus   CTI = cavotricuspid isthmus   RF = radiofrequency

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