Mechanism of Spontaneous Transition from Typical Atrial Flutter to Atrial Fibrillation: Role of Ectopic Atrial Fibrillation Foci

Hsieh, Ming‐Hsiung; Tai, Ching‐Tai; Tsai, Chin‐Feng; Yu, Wen-Chung; Lin, Wei‐Shiang; Huang, Jin‐Long; Ding, Yu‐An; Chang, Mau‐Song; Chen, Shih‐Ann

doi:10.1046/j.1460-9592.2001.00046.x

Cited by 41 publications

(34 citation statements)

References 17 publications

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“…Between the 3 ablation approaches for coexistent AF and AFL, several studies have demonstrated that the combined ablation strategy (PVAI+CTI) results in very low AF recurrence, 14,15 that PVAI alone without CTI ablation has an early recurrence of AFL in 24%, 16 and that the rate of AF recurrence after CTI isolation alone has been reported to be as high as 80% and up to 30% in those on AADs after isthmus isolation. 16 Roithinger et al 17 hypothesized that AF organizes to AFL in patients presenting with both arrhythmias.…”

Section: Discussionmentioning

confidence: 99%

Results From a Single-Blind, Randomized Study Comparing the Impact of Different Ablation Approaches on Long-Term Procedure Outcome in Coexistent Atrial Fibrillation and Flutter (APPROVAL)

Mohanty

Biase

et al. 2013

Circulation

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Background— This study examined the impact of different ablation strategies on atrial fibrillation (AF) recurrence and quality of life in coexistent AF and atrial flutter (AFL). Methods and Results— Three-hundred sixty enrolled patients with documented AF and AFL were blinded and randomized to group 1, AF±AFL ablation (n=182), or group 2, AFL ablation only (n=178). AF recurrence was evaluated with event recording and 7-day Holter at 3, 6, 9, and 12-month follow-ups. Quality of life was assessed at baseline and at the 12-month follow-up with 4 questionnaires: the Medical Outcome Study Short Form, the Hospital Anxiety and Depression Score, the Beck Depression Inventory, and the State-Trait Anxiety Inventory. Of the 182 patients in group 1, 58 (age, 63±8 years; 78% male; left ventricular ejection fraction, 59±8%) had AF+AFL ablation and 124 (age, 61±11 years; 72% male; left ventricular ejection fraction, 59±7%) had AF ablation only. In group 2 (age, 62±9 years; 76% male; left ventricular ejection fraction, 58±10%), only AFL was ablated by achieving bidirectional isthmus conduction block. Baseline characteristics were not different across groups. At 21±9 months of follow-up, 117 in group 1 (64%) and 34 in group 2 (19%) were arrhythmia free ( P <0.001). In group 1, scores on most quality-of-life subscales showed significant improvement at follow-up, whereas group 2 patients derived relatively minor benefit. Conclusions— In coexistent AF and AFL, lower recurrence rate and better quality of life are associated with AF ablation only or AF+AFL ablation than with lone AFL ablation. Furthermore, quality of life directly correlates with freedom from arrhythmia, as shown in this study for the first time in patients blinded to the procedure. Clinical Trial Registration— URL: http://www.clinicaltrial.gov/ . Unique identifier: NCT01439386.

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Section: Discussionmentioning

confidence: 99%

Results From a Single-Blind, Randomized Study Comparing the Impact of Different Ablation Approaches on Long-Term Procedure Outcome in Coexistent Atrial Fibrillation and Flutter (APPROVAL)

Mohanty

Biase

et al. 2013

Circulation

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“…That could be the result of non-PV sites acting as triggers (most of which were found in the right atrium) 23,24 or conditions (eg, right atrial dilatation, electrical remodeling, and fibrosis) that may act as substrate together being responsible for the initiation and maintenance of AF in group I.…”

Section: Is Common-type Afl a Sign Of An Arrhythmogenic Substrate In mentioning

confidence: 99%

Can Common-Type Atrial Flutter Be a Sign of an Arrhythmogenic Substrate in Paroxysmal Atrial Fibrillation?

et al. 2007

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Background-The coexistence of atrial fibrillation (AF) and atrial flutter (AFL) is well recognized. AF precedes the onset of AFL in almost all instances. We evaluated the effect of 2 ablation strategies in patients with paroxysmal AF (PAF) and AFL. Methods and Results-Ninety-eight patients with PAF/AFL were prospectively recruited to undergo pulmonary vein cryoisolation (PVI). Those with at least 1 episode of sustained common-type AFL were assigned to cavotricuspid isthmus cryoablation followed by a 6-week monitoring period and a subsequent PVI (nϭ36; group I). Patients with PAF only underwent PVI (nϭ62; group II). The study included 76 men with a mean age of 50Ϯ10 years. Most patients (76 [78%]) had no structural heart disease. When the 2 groups were compared, residual AF after a blanking period of 3 months after PVI occurred in 24 patients (67%) in group I versus 7 (11%) in group II (PϽ0.05). Conclusions-In patients with PAF and no documented common-type AFL, PVI alone prevented the occurrence of AF in 82%, whereas in patients with AFL/PAF, cavotricuspid isthmus cryoablation and PVI were used successfully to treat sustained common-type AFL but appeared to be insufficient to prevent recurrences of AF. In this population, AFL can be a sign that non-pulmonary vein triggers are the culprit behind AF or that sufficient electrical remodeling has already occurred in both atria, and thus a strategy that includes substrate modification may be required.

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“…These extrastimuli are possibly analogous to focal triggers that arise in the pulmonary veins, associated with the initiation of focal AF 8 or conversion of AFL to AF. 9 The explanation for the different effect of LAA and RAA extrastimuli on conversion of AFL to AF or termination of AFL is unclear. The tighter CI of LAA extrastimuli, greater distance of the LAA stimulation site from the AFL circuit, and multiple potential LA-to-RA wave-front breakthrough sites 26 may have resulted in a wave front that was more disorganized and fractionated when it encountered the AFL circuit.…”

Section: Atrial Remodeling and Focal Triggersmentioning

confidence: 99%

“…Recent studies have demonstrated the importance of pulmonary vein initiating triggers not only for the onset of paroxysmal AF 8 but possibly for the conversion of flutter to fibrillation. 9 In the present study, we investigated the hypothesis that in an anatomic model of AFL, progression to sustained AF would depend on the interaction between development of suitable atrial substrate and the presence of focal triggers to initiate the arrhythmia.…”

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confidence: 99%

Electrical Remodeling of the Atrium in an Anatomic Model of Atrial Flutter

et al. 2002

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Background-Atrial flutter (AFL) and atrial fibrillation (AF) frequently coexist, yet the specific relationship between these arrhythmias, and particularly whether sustained AFL leads to AF, is unknown. Methods and Results-We investigated the electrophysiological consequences of chronic AFL using an ovine anatomic right atrial Y-lesion model. AFL was induced in 7 animals, and 4 remained in sinus rhythm (controls). Sheep were monitored for spontaneous conversion of AFL to AF. Six of 7 sheep sustained AFL for 28 days. In 1 of 7 sheep, spontaneous conversion of AFL to AF occurred on day 5. AFL produced a highly significant fall in right and left atrial refractoriness (AERP, PϽ0.001), with 74Ϯ10% of the reduction occurring by day 3. Right atrial conduction velocity also fell significantly (baseline 89Ϯ9 cm/s versus day 28 64Ϯ14 cm/s, PϽ0.001) but over a slower time course. AERP and conduction velocity changes coincided with a characteristic biphasic decrease and increase in the AFL cycle length. The excitable gap (percent of AFL cycle length) increased from 13Ϯ3% at baseline to 46Ϯ8% by day 28 (PϽ0.001). Sustained AF (Ͼ30 seconds) was not inducible at baseline but after 28 days of AFL could be induced in 6 of 6 sheep by critically timed single or multiple extrastimuli delivered either in sinus rhythm or AFL. There was no significant change in any parameter in control sheep. Conclusions-In this model, AFL produced electrical remodeling and the substrate for sustained AF. However, spontaneous conversion to AF was uncommon, and the development of AF was dependent on specific triggers.

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Mechanism of Spontaneous Transition from Typical Atrial Flutter to Atrial Fibrillation: Role of Ectopic Atrial Fibrillation Foci

Cited by 41 publications

References 17 publications

Results From a Single-Blind, Randomized Study Comparing the Impact of Different Ablation Approaches on Long-Term Procedure Outcome in Coexistent Atrial Fibrillation and Flutter (APPROVAL)

Results From a Single-Blind, Randomized Study Comparing the Impact of Different Ablation Approaches on Long-Term Procedure Outcome in Coexistent Atrial Fibrillation and Flutter (APPROVAL)

Can Common-Type Atrial Flutter Be a Sign of an Arrhythmogenic Substrate in Paroxysmal Atrial Fibrillation?

Electrical Remodeling of the Atrium in an Anatomic Model of Atrial Flutter

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