title: Importance of ablating all potential right atrial flutter circuits in postcardiac surgery patients.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Cardiology, Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
authors.forename: Atul
authors.initials: A
authors.lastname: Verma
authors.forename: Nassir F
authors.initials: NF
authors.lastname: Marrouche
authors.forename: Niranjan
authors.initials: N
authors.lastname: Seshadri
authors.forename: Robert A
authors.initials: RA
authors.lastname: Schweikert
authors.forename: Mandeep
authors.initials: M
authors.lastname: Bhargava
authors.forename: J David
authors.initials: JD
authors.lastname: Burkhardt
authors.forename: Fethi
authors.initials: F
authors.lastname: Kilicaslan
authors.forename: Jennifer
authors.initials: J
authors.lastname: Cummings
authors.forename: Walid
authors.initials: W
authors.lastname: Saliba
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D001282:Atrial Flutter / Q000209:etiology / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D017115:Catheter Ablation; D002921:Cicatrix / Q000150:complications; D004562:Electrocardiography; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006325:Heart Atria; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence