Severe Left Ventricular Systolic Dysfunction Increases Atrial Fibrillation After Ablation of Atrial Flutter

Abstract

A 58 year old female underwent orthotopic left lung transplantation for emphysema. She enjoyed rapid recovery from her surgical procedure but developed almost daily episodes of symptomatic palpitations, persisting 32 months following transplant.Electrocardiogram demonstrated atypical atrial flutter, and she reported to the electrophysiology (EP) laboratory for mapping and catheter ablation.At EP study, she was found to have left atrial flutter, cycle length 230 ms, with variable atrioventricular conduction. Entrainment and activation mapping were both consistent with left atrial origin. Transseptal mapping demonstrated high frequency fractionated diastolic atrial electrograms recorded from the site of posterior anastamosis between the grafted pulmonary vein and the left atrium. Post pacing intervals recorded from this site were identical to the tachycardia cycle length. A single radiofrequency lesion terminated the tachycardia, rendering the patient noninducible. She has remained free of symptoms for over six months post ablation. This is the first published report of incisional reentrant atrial tachycardia involving a lung transplant. Standard entrainment mapping and radiofrequency ablation techniques proved satisfactory in curing the arrhythmia.Aim: cavo-tricuspidal isthmus (CTI) block assessment using right ventricular (RV) pacing in pts with ventriculo-atrial conduction.Methods: pts submitted to CTI ablation for typical atrial flutter were studied with a quadruple catheter in RV, a decapolar in the coronary sinus (CS), an eicosapolar around the tricuspidal annulus and an 8 mm ablator. Circumannular activation (CA) was analysed during CS and RV pacing in pts with spontaneous sinus rhythm or cardioverted during ablation. Pts without ventriculo-atrial conduction were excluded. The linear lesion was performed during RV pacing, looking at atrial signals splitting. CTI block was confirmed by analysis of CA during CS and RV pacing.Results: out of 15, 9 (60%) pts were included. Before ablation, during RV stimulation, the collision front of CA shifted counter clockwise with respect to CS pacing, without variation of Halo-like catheter activation time (82±31 ms vs 77±26, p=0.49). After ablation, CA was similar during CS and RV pacing, showing fully descending lateral right atrium activation (115±33 ms vs. 103±29, p=0.09). Double potentials on the ablation line were more splitted during CS pacing than RV pacing (126±24 ms vs. 108±20 ms, p=0.009), but less detached from the V wave. All pts were successfully ablated.Conclusions: in pts with ventriculo-atrial conduction, RV pacing can substitute CS pacing in the assessment of isthmus block.We ablated 26 patients with atrial flutter; in 13, a lateral line (LL) of isthmus block was drawn; in the other with draw a septal line (SPT); we used 8 mm non-irrigated tip catheters (60W power (PW); maximal temperature (TEMP) of 70 ºC -LL). With SPT, same catheters but 40W; 50ºC TEMP). In SPT we interrupted radiofrequency with high rate junctional rhythm (HJR) and looked for another po...

Heart failure and atrial flutter: a systematic review of current knowledge and practices

“…In four studies of highly selected patients with HF/ left ventricular systolic dysfunction (LVSD) and AFL referred for ablation, 33% overall (range 25% to 57%) had concurrent AF ( Table 2 ). 22 , 43 , 44 , 61 Following AFL ablation, AF developed in 17–30% of patients over 350 days to 2 years. 22 , 61 De novo AF was strongly associated with LVSD following AFL ablation:: 43% vs. 14% comparing LVEF < 50% vs. >50%, and 31% vs. 7% for LVEF < 35% vs. 36–55% in two US single‐centre cohorts.…”

“… 22 , 43 , 44 , 61 Following AFL ablation, AF developed in 17–30% of patients over 350 days to 2 years. 22 , 61 De novo AF was strongly associated with LVSD following AFL ablation:: 43% vs. 14% comparing LVEF < 50% vs. >50%, and 31% vs. 7% for LVEF < 35% vs. 36–55% in two US single‐centre cohorts. 22 , 61 In the remaining cohort and case series studying tachycardia‐induced cardiomyopathy, the small sample sizes limit meaningful conclusions regarding the overlap.…”

“…Thirty‐one studies described treatment of patients with AF or AFL, some or all having pre‐existing HF or LVSD ( Table 4 ). From these, 14 studies described the management separately for AF and AFL patients, of which 5 described electrical cardioversion, 10 catheter ablation, 8 , 22 , 40 , 41 , 42 , 43 , 44 , 45 , 61 , 68 and 9 drug therapy. 8 , 21 , 24 , 41 , 42 , 65 , 68 , 69 …”

“…Thirty-one studies described treatment of patients with AF or AFL, some or all having pre-existing HF or LVSD (Table 4). From these, 14 studies described the management separately for AF and AFL patients, of which 5 described electrical cardioversion, 10 catheter ablation, 8,22,[40][41][42][43][44][45]61,68 and 9 drug therapy. 8,21,24,41,42,65,68,69 For cardioversion, among 19 825 US inpatients with AFL (16% with existing HF), concurrent HF was associated with an increased odds of receiving electrical cardioversion during hospitalization.…”

Prospective Evaluation of a Standardized Screening for Atrial Fibrillation after Ablation of Cavotricuspid Isthmus Dependent Atrial Flutter

“…Ideally, patients with a higher baseline risk for developing newly diagnosed AF after cAFL ablation should be identified by risk factors, in order to direct resources for a more intense follow-up of these patients. Although some prior studies have identified such risk factors, including age [ 13 ], left ventricular dysfunction [ 1 , 14 , 15 ], left atrial dilatation [ 2 , 16 ] and arterial hypertension [ 1 ], these were not consistent across studies [ 17 ]. In our study, we only identified coronary artery disease as a significant predictor for recurrent AF or AT.…”