Risco de Fibrilação Atrial após Ablação de Flutter Dependente de Istmo Cavo-Tricuspídeo: Vale a Pena Fazer a Ablação da FA Simultaneamente?

Abstract

Background: Simultaneous ablation of atrial fibrillation (AF) and cavotricuspid isthmus (CTI)-dependent atrial flutter can be performed when both arrythmias had been recorded before the procedure. However, the best approach has not been defined in case of patients referred for ablation with CTI-dependent atrial flutter, without history of AF. Objectives: To assess the prevalence and to identify predictors of the first episode of AF after ablation of CTI-dependent atrial flutter in patients without history of AF. Methods: Retrospective cohort of patients with CTI-dependent atrial flutter without history of AF undergoing catheter ablation. Clinical characteristics were compared between patients who developed AF and those who did not have AF after the procedure. Significance level was set at 5%. In the analysis of predicting factors, the primary outcome was occurrence of AF after CTI-dependent atrial flutter ablation. Results: Of a total of 227 patients undergoing ablation of CTI-dependent atrial flutter (110 with history of AF and 33 without adequate follow-up), 84 were included, and 45 (53.6%) developed post-ablation AF. The HATCH and CHA2DS2-VASC scores were not different between the groups. Recurrence rate of CTI-dependent atrial flutter and complication rate were 11.5% and 1.2%, respectively, after ablation. Conclusions: Although ablation of CTI-dependent atrial flutter is a safe and effective procedure, 50% of the patients developed AF after the procedure. However, the role of combined ablation (CTI-dependent atrial flutter plus AF) aiming at preventing AF is still uncertain.

Minieditorial: Risco de FA após Ablação de Flutter Dependente de Istmo Cavo-Tricuspídeo: Vale a Pena Fazer a Ablação da FA Simultaneamente?

“…However, no predictive variables for the occurrence of AF were identified in the clinical follow-up. 7 The study of Bianco et al 7 is in agreement with previous studies of patients undergoing CTI-dependent AFL ablation. 1,[3][4][5] However, the question raised by the authors is whether we should perform a concomitant AF ablation in patients undergoing CTI-dependent AFL ablation without history of AF.…”

“…In this context, as have been acknowledged by Bianco et al, 7 a significant limitation of their study was the limited size of the study population which may have prevented the identification of predictors for development of AF after CTI ablation. As recognized by the authors, 7 if a risk profile for the occurrence of AF following CTI-dependent AFL ablation could be determined, a combined approach, including ablation of both arrhythmias, could be prophylactically indicated in patients at higher risk for developing AF.…”

“…1,[3][4][5] However, the question raised by the authors is whether we should perform a concomitant AF ablation in patients undergoing CTI-dependent AFL ablation without history of AF. As highlighted by Bianco et al, 7 the emergence of AF after ablation of CTI-dependent AFL has great clinical relevance due to the high risk of thromboembolic events associated with AF, particularly stroke. The presence of AF is associated with 4-5 times greater risk of developing ischemic stroke.…”

“…This effect has been reported in multiple studies examining the emergence of atrial arrhythmias, including AF, following CTI ablation for AFL. 1,[3][4][5] In this issue of the Arquivos Brasileiros de Cardiologia, Bianco et al 7 explore the incidence and predictors of AF following ablation of AFL. They present a series of 84 patients without any prior history of AF undergoing catheter ablation of CTI-dependent AFL, with data analyzed retrospectively.…”

“…Although AF ablation, by means of pulmonary vein isolation (PVI), is a more complex procedure, involving transseptal punctures, more extensive atrial ablation and use of three-dimensional mapping equipment, with higher costs and risks compared with CTI-dependent AFL ablation, an alternative strategy may be to treat both arrhythmias in a single ablation procedure, thus avoiding a second intervention. 7 In this context, recent data suggest that prophylactic PVI can be an effective strategy for preventing new AF in patients undergoing CTI-dependent AFL ablation. [10][11][12] The PREVENT AF I Study included 50 patients with CTI-dependent AFL without any prior history of AF, and randomized them in 1:1 fashion between CTI ablation alone versus CTI ablation plus cryoballoon PVI (CTI+PVI).…”