Abstract
Purpose
Pulmonary vein isolation (PVI) by cryoballoon ablation (CBA) has emerged as a commonly used technique for the treatment of atrial fibrillation. We sought to explore the incidence, risk factors for, and characterization of post-CBA-PVI atrial flutter.
Methods
We analyzed a prospective registry of patients who underwent CBA-PVI at a single institution. We included patients with more than 3 months of follow-up data and excluded those with a history of cavotricuspid isthmus (CTI) ablation. Locations of post-CBA-PVI atrial flutters were determined by analysis of intracardiac electrograms and electroanatomic maps.
Results
There were 556 patients included in the analysis. The mean age was 61.0 ± 10.6 years, 67.4% were male, the number of failed anti-arrhythmic medication trials was 1.2 ± 0.8, and the duration of atrial fibrillation pre-CBA was 54.3 ± 69.1 months. The 28-mm second-generation cryoballoon was used almost exclusively. Over a median follow-up time of 22.7 ± 17.9 months, 25 (4.5%) patients developed post-CBA-PVI atrial flutter after the 3-month blanking period. Of those 25 patients, 15 (60%) underwent subsequent ablation to eliminate the atrial flutter circuit, with 60% being CTI-dependent and the remainder left-sided (p value not significant). Risk factors for the development of atrial flutter included NYHA class ≥ 2 (OR 5.02, p < 0.001), presence of baseline bundle branch block (OR 4.33, p = 0.006), and left ventricular ejection fraction < 50% (OR 3.36, p = 0.007).
Conclusions
The rate of post-CBA-PVI atrial flutter is low after the blanking period even with medium-term follow-up. The origin of atrial flutter is equally divided between the right and left atria.
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References
Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339(10):659–66.
Kuck KH, Brugada J, Furnkranz A, Metzner A, Ouyang F, Chun KR, et al. Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation. N Engl J Med. 2016;374(23):2235–45.
Akerstrom F, Bastani H, Insulander P, Schwieler J, Arias MA, Jensen-Urstad M. Comparison of regular atrial tachycardia incidence after circumferential radiofrequency versus cryoballoon pulmonary vein isolation in real-life practice. J Cardiovasc Electrophysiol. 2014;25(9):948–52.
Wasserlauf J, Pelchovitz DJ, Rhyner J, Verma N, Bohn M, Li Z, et al. Cryoballoon versus radiofrequency catheter ablation for paroxysmal atrial fibrillation. Pacing Clin Electrophysiol : PACE. 2015;38(4):483–9.
Straube F, Dorwarth U, Ammar-Busch S, Peter T, Noelker G, Massa T, et al. First-line catheter ablation of paroxysmal atrial fibrillation: outcome of radiofrequency vs. cryoballoon pulmonary vein isolation. Europace. 2016;18(3):368–75.
Lee G, Sanders P, Kalman JM. Catheter ablation of atrial arrhythmias: state of the art. Lancet (London, England). 2012;380(9852):1509–19.
Coutino HE, de Asmundis C, Mugnai G, Moran D, De Regibus V, Stroker E, et al. Repeat procedures after second-generation cryoballoon ablation as an index procedure for persistent atrial fibrillation: one-year follow-up. J Interv Card Electrophysiol. 2016;47(3):365–71.
East C, Phan T, Filardo G, Franklin J, Donsky A, Wheelan KR, et al. Repeat ablation and hospitalization following cryoballoon ablation of atrial fibrillation at a single tertiary medical center. Proceedings. 2017;30(1):3–6.
Mikhaylov EN, Bhagwandien R, Janse PA, Theuns DA, Szili-Torok T. Regular atrial tachycardias developing after cryoballoon pulmonary vein isolation: incidence, characteristics, and predictors. Europace. 2013;15(12):1710–7.
Cardoso R, Mendirichaga R, Fernandes G, Healy C, Lambrakos LK, Viles-Gonzalez JF, et al. Cryoballoon versus radiofrequency catheter ablation in atrial fibrillation: a meta-analysis. J Cardiovasc Electrophysiol. 2016;27(10):1151–9.
Hermida A, Kubala M, Traulle S, Buiciuc O, Quenum S, Hermida JS. Prevalence and predictive factors of left atrial tachycardia occurring after second-generation cryoballoon ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2018;29(1):46–54.
Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017;14(10):e275–444.
Deo R, Berger R. The clinical utility of entrainment pacing. J Cardiovasc Electrophysiol. 2009;20(4):466–70.
Pedrinazzi C, Durin O, Mascioli G, Curnis A, Raddino R, Inama G, et al. Atrial flutter: from ECG to electroanatomical 3D mapping. Heart Int. 2006;2(3–4):161.
Cosio FG. Atrial flutter, typical and atypical: a review. Arrhythmia Electrophysiol Rev. 2017;6(2):55–62.
Medi C, Kalman JM. Prediction of the atrial flutter circuit location from the surface electrocardiogram. Europace. 2008;10(7):786–96.
Gerstenfeld EP, Dixit S, Bala R, Callans DJ, Lin D, Sauer W, et al. Surface electrocardiogram characteristics of atrial tachycardias occurring after pulmonary vein isolation. Heart Rhythm. 2007;4(9):1136–43.
Steinberg JS, Romanov A, Musat D, Preminger M, Bayramova S, Artyomenko S, et al. Prophylactic pulmonary vein isolation during isthmus ablation for atrial flutter: the PReVENT AF Study I. Heart Rhythm. 2014;11(9):1567–72.
Mesquita J, Ferreira AM, Cavaco D, Carmo P, Madeira M, Freitas P, et al. Impact of prophylactic cavotricuspid isthmus ablation in atrial fibrillation recurrence after a first pulmonary vein isolation procedure. Int J Cardiol. 2018;259:82–7.
Nery PB, Belliveau D, Nair GM, Bernick J, Redpath CJ, Szczotka A, et al. Relationship between pulmonary vein reconnection and atrial fibrillation recurrence: A Systematic Review and Meta-Analysis. JACC Clin Electrophysiol. 2016;2(4):474–83.
Rahman F, Wang N, Yin X, Ellinor PT, Lubitz SA, LeLorier PA, et al. Atrial flutter: clinical risk factors and adverse outcomes in the Framingham Heart Study. Heart Rhythm. 2016;13(1):233–40.
Da Costa A, Mourot S, Romeyer-Bouchard C, Thevenin J, Samuel B, Kihel A, et al. Anatomic and electrophysiological differences between chronic and paroxysmal forms of common atrial flutter and comparison with controls. Pacing Clin Electrophysiol: PACE. 2004;27(9):1202–11.
Medi C, Teh AW, Roberts-Thomson K, Morton JB, Kistler PM, Kalman JM. Right atrial remodeling is more advanced in patients with atrial flutter than with atrial fibrillation. J Cardiovasc Electrophysiol. 2012;23(10):1067–72.
Nattel S, Shiroshita-Takeshita A, Cardin S, Pelletier P. Mechanisms of atrial remodeling and clinical relevance. Curr Opin Cardiol. 2005;20(1):21–5.
Talman V, Ruskoaho H. Cardiac fibrosis in myocardial infarction-from repair and remodeling to regeneration. Cell Tissue Res. 2016;365(3):563–81.
Manolis AS. Contemporary diagnosis and management of atrial flutter: a continuum of atrial fibrillation and vice versa? Cardiol Rev. 2017;25(6):289–97.
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JRBConcept/design, data analysis/interpretation, drafting article.
RKConcept/design, critical revision of article.
CLD, GP, AABData collection, critical revision of article.
AT, JW, ABC, RA, SK, AL, NVData acquisition, approval of article.
BPKConcept/design, critical revision of article.
RSPConcept/design, data analysis/interpretation, drafting article, critical revision of article.
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The institutional review board at Northwestern University approved the study protocol.
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Bradley P. Knight receives honoraria for consulting and speaking for Medtronic Inc. Rod S. Passman receives research support, consulting fees, and speaker fees from Medtronic; royalties from UpToDate; and research support from Pfizer and Kardia. Northwestern University receives fellowship support from Medtronic, Inc.
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Baman, J.R., Kaplan, R.M., Diaz, C.L. et al. Characterization of atrial flutter after pulmonary vein isolation by cryoballoon ablation. J Interv Card Electrophysiol 57, 233–240 (2020). https://doi.org/10.1007/s10840-019-00560-9
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DOI: https://doi.org/10.1007/s10840-019-00560-9