Is prophylactic ablation of the cavotricuspid and peri‐incisional isthmus justified in patients with postoperative atrial flutter after right atriotomy?

Abstract

Background: The two most common postoperative atrial flutter (AFL) circuits after right atriotomy are the cavotricuspid isthmus (CTI) dependent and the lateral, peri-incisional. We investigated whether radiofrequency ablation (RFA) of both circuits results in more favorable long-term outcomes. Methods: Single-center retrospective cohort study of consecutive patients who underwent RFA of AFL after open-heart surgery. The effect of surgery type and RFA strategy on AFL recurrence was evaluated. Results: One hundred and forty-two patients (mean age 64.5 ± 12.7 years, 65.% male) were enrolled. Patients with right atrial (RA) flutter (n = 124) were divided into two groups based on the index RFA procedure: only one RA circuit was ablated (Group 1, n = 84, 67.7%) or both the CTI and the peri-incisional circuit ablated (Group 2, n = 40, 32.3%). The previous open-heart surgery was categorized based on the extension of the RA incision: limited (Type A) or extended (Type B) atriotomy.After a mean follow-up of 36 ± 28 months, flutter recurrence was not different among patients with limited RA atriotomy (25% vs. 22% in Groups 1A and 2A, respectively, p = 1.0). However, after type B surgery, ablation of both AFL circuits was associated with a reduced recurrence rate (63% vs. 26% in Groups 1B and 2B, respectively, p = .002). Conclusions:In patients with postoperative RA flutter after extended right atriotomy, ablation of both the CTI and the peri-incisional isthmus significantly reduces the AFL recurrence rate. Prophylactic ablation of both isthmi, even if not proven to support reentry, is reasonable in this population.

Ready to deploy prophylactics?

“…The findings of this study are largely in line with the prior reported balance of typical versus atypical AFL observed after cardiac surgery. We previously reported on a cohort of patients undergoing ablation of AFL, and in those who had undergone prior cardiac surgery, atypical AFL was more common when compared to patients without prior cardiac surgery and the presence of prior cardiac surgery was found to be an independent predictor of scar-related AFL, 2 consistent with the observations of Benak et al 1 The reported findings have several important clinical implications. First, patients presenting to the EP lab for catheter ablation with ECG suggesting typical AFL after cardiac surgery should undergo a thorough assessment to establish the mechanism and site of origin so that effective ablation therapy can be delivered.…”

“…The findings of this study are largely in line with the prior reported balance of typical versus atypical AFL observed after cardiac surgery. We previously reported on a cohort of patients undergoing ablation of AFL, and in those who had undergone prior cardiac surgery, atypical AFL was more common when compared to patients without prior cardiac surgery and the presence of prior cardiac surgery was found to be an independent predictor of scar‐related AFL, 2 consistent with the observations of Benak et al 1 …”

“…All in all, we congratulate Benak 1 and colleagues for their provocative contribution to the area of arrhythmia management following cardiac surgery and for their intriguing notion of prophylactic ablation of per‐incisional/scar dependent AFL in such patients. We are still searching for the right time and place to deploy prophylactics in arrhythmia management.…”

“…In this issue of the Journal, Benak 1 and colleagues report a series of patients undergoing catheter ablation of AFL that followed cardiac surgery. All patients had right atriotomy which predisposes to the development of both typical and atypical (or incision‐dependent) AFL.…”