Ablation outcomes for atypical atrial flutter versus recurrent atrial fibrillation following index pulmonary vein isolation

Akhtar, Tauseef; Daimee, Usama A.; Sivasambhu, Bhradeev; Boyle, Thomas A.; Arbab‐Zadeh, Armin; Marine, Joseph E.; Berger, Ronald D.; Calkins, Hugh; Spragg, David D.

doi:10.1111/jce.15051

Cited by 5 publications

(6 citation statements)

References 17 publications

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“…AAFl has reoccurred in 12.7% of patients. It has been found that left atrial diameter and volume were greater in patients with the recurrence of AAFl than in patients who developed AF after prior ablation of the atrium [10]. We did not analyze this variable, but interestingly, contrary to our findings, male sex or antiarrhythmics prescription was not associated with arrhythmia-free survival in this analysis.…”

Section: Discussioncontrasting

confidence: 93%

Atypical atrial flutter ablation: follow-up and predictors of arrhythmia recurrence

Michał,

Bartosz,

Kacper

et al. 2024

Heart Vessels

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Background: Ablation techniques have evolved greatly with advances in high-density 3D mapping systems over the last few years. Some patients develop atypical atrial flutter (AAFL) after pulmonary vein isolation (PVI). The data regarding follow-up after AAFL ablation as well as predictors of arrhythmia recurrence are lacking. This analysis aims to report procedure success rates and establish predictors of long-term success. Methods and Results: This retrospective cohort study included 45 patients (median age: 69 years; 40% female) who qualified for their first AAFL after PVI. The procedures were performed with the use of conventional ablation-index-guided ThermoCool Smarttouch SF and QDOT MICRO catheters. Freedom from arrhythmia recurrence was used as a primary end point. After 52 weeks of follow-up, 60% of patients suffered from arrhythmia recurrence, but over 70% of the studied cohort reported symptom improvement. In multivariate analysis, class I antiarrhythmics prescription (HR = 0.24 [95% CI 0.06–0.94], p = 0.04) was associated with the lack of arrhythmia recurrence during the follow-up, while cardioversion during procedure was associated with increased risk of arrhythmia recurrence (HR = 7.05 [95% CI 2.09–23.72], p = 0.002). Conclusions: Long-term success of AAFL ablation procedures is not satisfactory despite improvement in symptoms. Class I antiarrhythmics prescription at the discharge contributes to higher chances of sinus rhythm maintenance, whereas cardioversion during the procedure is related to increased risk of arrhythmia recurrence.

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Section: Discussioncontrasting

confidence: 93%

Atypical atrial flutter ablation: follow-up and predictors of arrhythmia recurrence

Michał,

Bartosz,

Kacper

et al. 2024

Heart Vessels

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“…Clinically, atypical flutters sustained by AR drivers can be common after PVI, affecting up to 10% of patients following radiofrequency ablation. 44 , 45 , 46 , 47 Thus, our study provides reasonable explanation for the incidence of these tachyarrhythmias via anatomically AR around the mitral valve. The remaining 90% of recurrent AF cases may be attributed to emergent or preserved FRs, as previously suggested.…”

Section: Discussionsupporting

confidence: 64%

Explainable Machine Learning to Predict Anchored Reentry Substrate Created by Persistent Atrial Fibrillation Ablation in Computational Models

Bifulco,

Macheret,

Scott

et al. 2023

JAHA

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Background Postablation arrhythmia recurrence occurs in ~40% of patients with persistent atrial fibrillation. Fibrotic remodeling exacerbates arrhythmic activity in persistent atrial fibrillation and can play a key role in reentrant arrhythmia, but emergent interaction between nonconductive ablation‐induced scar and native fibrosis (ie, residual fibrosis) is poorly understood. Methods and Results We conducted computational simulations in pre‐ and postablation left atrial models reconstructed from late gadolinium enhanced magnetic resonance imaging scans to test the hypothesis that ablation in patients with persistent atrial fibrillation creates new substrate conducive to recurrent arrhythmia mediated by anchored reentry. We trained a random forest machine learning classifier to accurately pinpoint specific nonconductive tissue regions (ie, areas of ablation‐delivered scar or vein/valve boundaries) with the capacity to serve as substrate for anchored reentry‐driven recurrent arrhythmia (area under the curve: 0.91±0.03). Our analysis suggests there is a distinctive nonconductive tissue pattern prone to serving as arrhythmogenic substrate in postablation models, defined by a specific size and proximity to residual fibrosis. Conclusions Overall, this suggests persistent atrial fibrillation ablation transforms substrate that favors functional reentry (ie, rotors meandering in excitable tissue) into an arrhythmogenic milieu more conducive to anchored reentry. Our work also indicates that explainable machine learning and computational simulations can be combined to effectively probe mechanisms of recurrent arrhythmia.

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“…To our knowledge, this is the first study reporting follow‐up of MAF ablation out to 4 years. The recurrence of atrial arrhythmias after ablation remains high and seems to increase over time 5,6,22,25,26 . In this study, the MIL line was associated with greater freedom from recurrent atrial arrhythmias over a 4‐year follow‐up period, with less recurrent atrial flutter.…”

Section: Discussionmentioning

confidence: 57%

Comparison of anterior mitral line and mitral isthmus line for ablation of mitral annular flutter

Neira,

Hanson,

Tso

et al. 2024

Cardiovasc electrophysiol

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BackgroundMitral annular flutter (MAF) is the most common left atrial macro‐reentrant arrhythmia following catheter ablation of atrial fibrillation (AF). The best ablation approach for this arrhythmia remains unclear.MethodsThis single‐center, retrospective study sought to compare the acute and long‐term outcomes of patients with MAF treated with an anterior mitral line (AML) versus a mitral isthmus line (MIL). Acute ablation success, complication rates, and long‐term arrhythmia recurrence were compared between the two groups.ResultsBetween 2015 and 2021, a total of 81 patients underwent ablation of MAF (58 with an AML and 23 with a MIL). Acute procedural success defined as bidirectional block was achieved in 88% of the AML and 91% of the MIL patients respectively (p = 1.0). One year freedom from atrial arrhythmias was 49.5% versus 77.5% and at 4 years was 24% versus 59.6% for AML versus MIL, respectively (hazard ratio [HR]: 0.38, confidence interval [CI]: 0.17–0.82, p = .009). Fewer patients in the MIL group had recurrent atrial flutter when compared to the AML group (HR: 0.32, CI: 0.12–0.83, p = .009). The incidence of recurrent AF, on the other side, was not different between both groups (21.7% vs. 18.9%; p = .76). There were no serious adverse events in either group.ConclusionIn this retrospective study of patients with MAF, a MIL compared to AML was associated with a long‐term reduction in recurrent atrial arrhythmias driven by a reduction in macroreentrant atrial flutters.

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Ablation outcomes for atypical atrial flutter versus recurrent atrial fibrillation following index pulmonary vein isolation

Cited by 5 publications

References 17 publications

Atypical atrial flutter ablation: follow-up and predictors of arrhythmia recurrence

Atypical atrial flutter ablation: follow-up and predictors of arrhythmia recurrence

Explainable Machine Learning to Predict Anchored Reentry Substrate Created by Persistent Atrial Fibrillation Ablation in Computational Models

Comparison of anterior mitral line and mitral isthmus line for ablation of mitral annular flutter

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