Atrial flutter catheter ablation in adult patients with repaired tetralogy of Fallot: mechanisms and outcomes of percutaneous catheter ablation in a consecutive series.
BACKGROUND
Prior investigators note successful ablation of both typical cavotricuspid isthmus-dependent and scar-related macroreentrant right atrial flutters (AFL) in adult patients with repaired tetralogy of Fallot (TOF). However, an analysis of the mechanisms (including a description of a uniform approach to diagnose such mechanisms), and clinical outcomes of catheter ablation in a consecutive series of adult patients with AFL late after surgical TOF repair has not been previously reported.


METHODS
Background clinical data and follow-up were evaluated in a consecutive series of TOF patients evaluated from September 2001 to June 2008.


RESULTS
We report a prevalence of sustained, symptomatic AFL in patients with repaired TOF equal to 20% (28/140 patients), and of recurrent, drug-refractory and/or severely symptomatic AFL to be 11% (16/140 patients). The AFLs manifested variable cycle lengths ranging from 215 to 525 ms. Underlying mechanisms were: (1) cavotricuspid (CTI)-dependent, counterclockwise atrial flutter (n=8 patients); (2) non-CTI-dependent macroreentrant scar-related AFL (n=6 patients); and (3) both CTI- and non-CTI-dependent macroreentrant AFL (n=2 patients). Recurrent arrhythmias occurred in six patients, five of whom were successfully treated with repeat ablation. After a mean follow-up of 23 months, 15 of 16 patients were alive and free of sustained AFL.


CONCLUSIONS
AFL late after surgical TOF repair occurs in 20% of such patients. In more than half of these patients, the AFLs are drug-refractory and/or severely symptomatic. Despite the presence of congenital heart disease treated with prior cardiac surgery and AFLs with variable atrial cycle lengths, the CTI-dependent mechanism underlies approximately half of the sustained, symptomatic AFLs.
Biviano
Angelo
A
Department of Medicine, Cardiology Division, Columbia University College of Physicians and Surgeons, New York, NY, USA. ab542@columbia.edu
Garan
Hasan
H
Hickey
Kathleen
K
Whang
William
W
Dizon
Jose
J
Rosenbaum
Marlon
M
D000328:Adult; D001282:Atrial Flutter / Q000453:epidemiology / Q000209:etiology* / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012008:Recurrence; D012189:Retrospective Studies; D013771:Tetralogy of Fallot / Q000150:complications* / Q000601:surgery; D016896:Treatment Outcome
J Am Coll Cardiol. 2002 Jun 5;39(11):1827-35
12039499
J Am Coll Cardiol. 1997 Oct;30(4):1032-8
9316535
Circulation. 1996 Aug 1;94(3):407-24
8759083
Eur Heart J. 2004 Jun;25(11):963-9
15172468
Am J Cardiol. 2001 Mar 1;87(5):584-8
11230843
Circulation. 1995 Apr 15;91(8):2214-9
7697851
Circulation. 1995 Oct 1;92(7):1839-48
7671368
J Am Coll Cardiol. 1993 Sep;22(3):883-90
8354828
Heart Rhythm. 2004 Sep;1(3):268-75
15851168
Pacing Clin Electrophysiol. 2003 Jan;26(1P2):420-5
12687858
Circulation. 1992 Oct;86(4):1233-40
1394929
Arch Cardiovasc Dis. 2008 Sep;101(9):533-8
19041837
Am J Cardiol. 2000 Nov 1;86(9):969-74
11053709
Circulation. 2001 Feb 6;103(5):699-709
11156882
J Am Coll Cardiol. 2000 Feb;35(2):428-41
10676691
Ann Thorac Surg. 2006 May;81(5):1786-93; discussion 1793
16631673
Circulation. 1996 Aug 1;94(3):398-406
8759082
Am J Cardiol. 2003 Oct 1;92(7):879-81
14516900
Circulation. 1995 Feb 1;91(3):707-14
7828297
Circulation. 2001 Apr 24;103(16):2060-5
11319195
Circulation. 1994 Dec;90(6):2804-14
7994824
J Am Coll Cardiol. 1985 Oct;6(4):871-8
4031302
Am J Cardiol. 1996 May 1;77(11):985-91
8644650
Circulation. 2000 Sep 12;102(11):1283-9
10982544
Circulation. 2007 Jun 26;115(25):3224-34
17592091
Card Electrophysiol Rev. 2002 Dec;6(4):422-30
12438823