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CLINICAL RESEARCH: HEART RHYTHM DISORDERS

The need for atrial flutter ablation following pulmonary vein antrum isolation in patients with and without previous cardiac surgery

Fethi Kilicaslan, MD^*, Atul Verma, MD^*, Hirosuke Yamaji, MD^*, Nassir F. Marrouche, MD^*, Oussama Wazni, MD^*, Jennifer E. Cummings, MD^*, Steven Hao, MD, Michelle Williams Andrews, RN^*, Salwa Beheiry, RN, Ahmad Abdul-Karim, MD^*, William A. Belden, MD^*, Stephen Minor, MD^*, J. David Burkhardt, MD^*, Walid Saliba, MD^*, Robert A. Schweikert, MD^* and Andrea Natale, MD^*,*

^* Cleveland Clinic Foundation, Section of Pacing and Electrophysiology, Cleveland, Ohio
Sutter Pacific Heart Centers, San Francisco, California

Manuscript received August 23, 2004; revised manuscript received October 20, 2004, accepted November 15, 2004.

^* Reprint requests and correspondence: Dr. Andrea Natale, Section of Pacing and Electrophysiology, Cleveland Clinic Foundation, Desk F15, 9500 Euclid Avenue, Cleveland, Ohio 44195. (Email: natalea{at}ccf.org).

OBJECTIVES: The aim of this study was to assess the incidence of atrial flutter (AFL) after pulmonary vein antrum isolation (PVAI) in patients with previous cardiac surgery (PCS) in comparison to patients without PCS and to assess the need for AFL ablation in both groups.

BACKGROUND: Atrial fibrillation (AF) and AFL often co-exist. Pulmonary vein antrum isolation may be sufficient to control both arrhythmias. However, in patients with PCS, atrial incisions, cannulations, and scar areas may cause AFL recurrence despite elimination of pulmonary vein triggers.

METHODS: Data from 1,345 patients who had PVAI were analyzed. Patients with a history of AFL ablation and patients who had concomitant AFL ablation during PVAI were excluded from analysis. Sixty-three patients constituted the PCS group (Group 1, age 57 ± 13 years, 12 female) and 1,062 patients constituted the non-PCS group (Group 2, age 55 ± 12 years, 212 female). Patients in Group 1 had larger left atria, higher incidence of AFL pre-PVAI, and lower ejection fraction.

RESULTS: There was no significant difference in post-PVAI AF recurrence between Groups 1 and 2, but AFL incidence after PVAI was higher in Group 1 (33% vs. 4%, p < 0.0001). Ablation of AFL in Group 1 patients resulted in an 86% acute success rate and 11% recurrence over a mean follow-up of 357 ± 201 days.

CONCLUSIONS: In patients with PCS, post-PVAI AF recurrence is similar to patients without PCS. However, history of PCS is associated with a higher recurrence of AFL after PVAI. In a significant number of patients with PCS, AFL ablation is required to achieve a cure.

Abbreviations and Acronyms   AF = atrial fibrillation   AFL = atrial flutter   ASD = atrial septal defect   AVR = aortic valve replacement   CABG = coronary artery bypass graft surgery   LA = left atrium/atrial   MVR = mitral valve replacement   PCS = previous cardiac surgery   PV = pulmonary vein   PVAI = pulmonary vein antrum isolation   RA = right atrium/atrial   RF = radiofrequency

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