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A simplified differential pacing technique for the evaluation of bidirectional cavo-tricuspid isthmus block during ablation of typical atrial flutter

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Abstract

Purpose

Bidirectional block of the cavo-tricuspid isthmus (CTI) is an established endpoint of CTI-dependent atrial flutter (AFl) ablation. Differential pacing has been used to evaluate the CTI block. The purpose of this study is to describe a modified differential pacing technique to evaluate the CTI block.

Methods

Sixty-two patients underwent radiofrequency (RF) ablation of CTI-dependent AFl. The acute endpoints were non-inducibility of the AFl, and verification of the bidirectional CTI block by our methodology. Pacing was performed in the CS with an ablation catheter positioned immediately lateral to the CTI ablation line, and then 1–2 cm more laterally. The stimulus-to-ablation catheter atrial electrogram intervals were measured at these sites (StimCS-Abl1 and StimCS-Abl2, respectively). Pacing with the ablation catheter also was performed at these 2 sites, and the stimulus-to-CS electrogram intervals (StimABL1-CS and StimABL2-CS) were measured. The criteria for the bidirectional block were StimCS-Abl1 > StimCS-Abl2, and StimABL1-CS > StimABL2-CS. Clinical efficacy was defined as freedom from recurrent AFl during follow-up.

Results

Following 12.2 ± 3.7 min of RF delivery across the CTI, intervals were StimCS-Abl1 = 181.2 ± 22.7 ms and StimABL1-CS = 181.0 ± 23.6 ms, and StimCS-Abl2 = 152.2 ± 26.5 ms and StimABL2-CS = 151.2 ± 22.7 (P < 0.001). Atrial flutter was rendered not inducible in all patients, and no procedural complications were encountered. During the next 15.9 ± 0.7 months, two patients were lost to follow-up, and among the 62 other patients, one (1.7%) had flutter recurrence.

Conclusions

The bidirectional CTI block can be assessed quickly and easily using only the ablation and CS catheters for differential pacing.

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References

  1. Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2016;67:1575–623.

    Article  Google Scholar 

  2. Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomstrom-Lundqvist C, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2020;41:655–720.

    Article  Google Scholar 

  3. Natale A, Newby KH, Pisanó E, Leonelli F, Fanelli R, Potenza D, et al. Prospective randomized comparison of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter. J Am Coll Cardiol. 2000;35:1898–904.

    Article  CAS  Google Scholar 

  4. Da Costa A, Thévenin J, Roche F, Romeyer-Bouchard C, Abdellaoui L, Messier M, et al. Results from the Loire-Ardèche-Drôme-Isère-Puy-de-Dôme (LADIP) Trial on atrial flutter, a multicentric prospective randomized study comparing amiodarone and radiofrequency ablation after the first episode of symptomatic atrial flutter. Circulation. 2006;114:1676–81.

    Article  Google Scholar 

  5. Tada H, Oral H, Ozaydin M, Chugh A, Scharf C, Hassan S, et al. Randomized comparison of anatomic and electrogram mapping approaches to ablation of typical atrial flutter. J Cardiovasc Electrophysiol. 2002;13:662–6.

    Article  Google Scholar 

  6. Tada H, Oral H, Sticherling C, Chough SP, Baker RL, Wasmer K, et al. Double potentials along the ablation line as a guide to radiofrequency ablation of typical atrial flutter. J Am Coll Cardiol. 2001;38:750–5.

    Article  CAS  Google Scholar 

  7. Yokokawa M, Sinno MC, Saeed M, Latchamsetty R, Ghanbari H, Crawford T, et al. The relationship between the P wave and local atrial electrogram in predicting conduction block during catheter ablation of cavo-tricuspid isthmus-dependent atrial flutter. J Interv Card Electrophysiol. 2018;53:187–93.

    Article  Google Scholar 

  8. Madaffari A, Krisai P, Spies F, Knecht S, Schaer B, Kojic D, et al. Ablation of typical atrial flutter guided by the paced PR interval on the surface electrocardiogram: a proof of concept study. Europace. 2019;21:1750–4.

    Article  Google Scholar 

  9. Shah D, Haissaguerre M, Takahashi A, Jais P, Hocini M, Clementy J. Differential pacing for distinguishing block from persistent conduction through an ablation line. Circulation. 2000;102:1517–22.

    Article  CAS  Google Scholar 

  10. Cosio FG. Atrial flutter, typical and atypical: a review. Arrhythmia Electrophysiol Rev. 2017;6:55–62.

    Article  Google Scholar 

  11. Katritsis DG, Boriani G, Cosio FG, Hindricks G, Jais P, Josephson ME, et al. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE). Europace. 2017;19:465–511.

    Article  Google Scholar 

  12. Maury P, Raczka F, Gaty D, Duparc A, Couderc P, Hollington L, et al. Radio-frequency ablation of atrial flutter: long-term results and predictive value of cavo-tricuspid isthmus bidirectional block as determined by a simplified technique. Cardiology. 2008;110:17–28.

    Article  Google Scholar 

  13. Pastor A, Nunez A, Guzzo G, de Diego C, Cosio FG. A simple pacing method to diagnose postero-anterior (clockwise) cavo-tricuspid isthmus block after radiofrequency ablation. Europace. 2010;12:1290–5.

    Article  Google Scholar 

  14. Rosu R, Abdelaal A, Andronache M, Gusetu G, Muresan L, Martins R, et al. Assessment of the correlation between two defining criteria for bidirectional isthmic block in the ablation of typical atrial flutter. Indian Pacing Electrophysiol J. 2011;10:536–46.

    CAS  PubMed  PubMed Central  Google Scholar 

  15. Glover BM, Chen J, Hong KL, Boveda S, Baranchuk A, Haugaa KH, et al. Catheter ablation for atrial flutter: a survey by the European Heart Rhythm Association and Canadian Heart Rhythm Society. Europace. 2016;18:1880–5.

    Article  Google Scholar 

  16. Yang Y, Wahba GM, Liu T, Mangat I, Keung EC, Ursell PC, et al. Site specificity of transverse crista terminalis conduction in patients with atrial flutter. Pacing Clin Electrophysiol. 2005;28:34–43.

    Article  Google Scholar 

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Authors and Affiliations

  1. Hygeia Hospital, 4 Erythrou Stavrou Str, 15123, Athens, Greece

    Demosthenes G. Katritsis, Theodoros Zografos & George Paxinos

  2. University of Michigan Health System, Ann Arbor, MI, USA

    Ronpichai Chokesuwattanaskul, Sina Jame & Fred Morady

Authors
  1. Demosthenes G. Katritsis
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  2. Ronpichai Chokesuwattanaskul
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  3. Theodoros Zografos
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  4. Sina Jame
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  5. George Paxinos
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Correspondence to Demosthenes G. Katritsis.

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Katritsis, D.G., Chokesuwattanaskul, R., Zografos, T. et al. A simplified differential pacing technique for the evaluation of bidirectional cavo-tricuspid isthmus block during ablation of typical atrial flutter. J Interv Card Electrophysiol 63, 109–114 (2022). https://doi.org/10.1007/s10840-020-00935-3

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  • DOI: https://doi.org/10.1007/s10840-020-00935-3

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