title: Atrial flutter catheter ablation in adult patients with repaired tetralogy of Fallot: mechanisms and outcomes of percutaneous catheter ablation in a consecutive series.
abstract: 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.
authors.affiliation: Department of Medicine, Cardiology Division, Columbia University College of Physicians and Surgeons, New York, NY, USA. ab542@columbia.edu
authors.forename: Angelo
authors.initials: A
authors.lastname: Biviano
authors.forename: Hasan
authors.initials: H
authors.lastname: Garan
authors.forename: Kathleen
authors.initials: K
authors.lastname: Hickey
authors.forename: William
authors.initials: W
authors.lastname: Whang
authors.forename: Jose
authors.initials: J
authors.lastname: Dizon
authors.forename: Marlon
authors.initials: M
authors.lastname: Rosenbaum
mesh_terms: 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
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