Importance of ablating all potential right atrial flutter circuits in postcardiac surgery patients.
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.
Verma
Atul
A
Department of Cardiology, Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Marrouche
Nassir F
NF
Seshadri
Niranjan
N
Schweikert
Robert A
RA
Bhargava
Mandeep
M
Burkhardt
J David
JD
Kilicaslan
Fethi
F
Cummings
Jennifer
J
Saliba
Walid
W
Natale
Andrea
A
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