Voltage‐Guided Ablation Technique for Cavotricuspid Isthmus‐Dependent Atrial Flutter: Refining the Continuous Line

Abstract

Ablation of the cavotricuspid isthmus has become first-line therapy for "isthmus-dependent" atrial flutter. The goal of ablation is to produce bidirectional cavotricuspid isthmus block. Traditionally, this has been obtained by creation of a complete ablation line across the isthmus from the ventricular end to the inferior vena cava. This article describes an alternative method used in our laboratory. There is substantial evidence that conduction across the isthmus occurs preferentially over discrete separate bundles of tissue. Consequently, voltage-guided ablation targeting only these bundles with large amplitude atrial electrograms results in a highly efficient alternate method for the interruption of conduction across the cavotricuspid isthmus. Understanding the bundle structure of conduction over the isthmus facilitates more flexible approaches to its ablation and targeting maximum voltages in our hands has resulted in reduction of ablation time and fewer recurrences.

Characteristics of Cavotricuspid Isthmus Ablation for Atrial Flutter Guided by Novel Parameters Using a Contact Force Catheter

“…Each operator (PAG, GCK, and KD) in the study has experience of >500 electrophysiological ablation procedures. The ablation approach employed was a maximal voltage guided (MVG) point‐by‐point ablation approach where the position of ablation lesion site was sequentially guided by the maximum voltage on the CTI, but all the other aspects of the ablation lesion were guided by the contact force parameters in the Study cohort. In the Control cohort the MVG ablation approach was also employed without CF parameters and was guided by traditional parameters.…”

Variable Procedural Strategies Adapted to Anatomical Characteristics in Catheter Ablation of the Cavotricuspid Isthmus Using a Preoperative Multidetector Computed Tomography Analysis

“…Therefore, we used an 8 mm tip catheter throughout the study. The usefulness of a voltage‐guided technique to target the high‐voltage electrograms along the CTI to ablate the functionally important anatomical muscle bundles was reported recently . The results of this study may be useful for overcoming difficult cases with this approach.…”

“…The usefulness of a voltage-guided technique to target the high-voltage electrograms along the CTI to ablate the functionally important anatomical muscle bundles was reported recently. 21,22 The results of this study may be useful for overcoming difficult cases with this approach. When the catheter contact is poor, the catheter inversion technique will be necessary to map the target electrograms.…”

Cavotricuspid Isthmus-Dependent Atrial Flutter. Beyond Simple Linear Ablation

“…The objective of isthmus-dependent atrial flutter ablation is to achieve CTI bidirectional electrical block. To accomplish this goal, various strategies are currently employed [ 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 ] (Table 1 , Ref. [ 127 , 128 , 129 , 130 , 131 , 133 , 134 , 136 , 137 , 140 , 141 ]):…”

“…(c) Point applications directed by maximum voltage criteria [ 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 ]. This approach is based on the observation that conduction across the CTI occurs preferentially over discrete separate bundles of myocardial tissue.…”