Abstract
Atrial flutter and atrial fibrillation are two of the most common arrhythmias seen in clinical practice and the most common indications for referral for catheter ablation. While they are historically grouped together, research over the past 20 years has shown that atrial flutter and atrial fibrillation are distinct arrhythmias with different electrophysiological mechanisms. This review will consider the development of and current approach to catheter ablation of atrial flutter and atrial fibrillation.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Waldo AL, MacLean WA, Karp RB, Kouchoukos NT, James TN (1977) Entrainment and interruption of atrial flutter with atrial pacing: studies in man following open heart surgery. Circulation 56:737–745
Watson RM, Josephson ME (1980) Atrial flutter. I. Electrophysiologic substrates and modes of initiation and termination. Am J Cardiol 45:732–741
Cosio FG, Goicolea A, López-Gil M et al (1990) Atrial endocardial mapping in the rare form of atrial flutter. Am J Cardiol 66:715–720
Olgin JE, Kalman JM, Fitzpatrick AP, Lesh MD (1995) Role of right atrial endocardial structures as barriers to conduction during human type I atrial flutter. Activation and entrainment mapping guided by intracardiac echocardiography. Circulation 92:1839–1848
Olgin JE, Kalman JM, Lesh MD (1996) Conduction barriers in human atrial flutter: correlation of electrophysiology and anatomy. J Cardiovasc Electrophysiol 7:1112–1126
Klein GJ, Guiraudon GM, Sharma AD, Milstein S (1986) Demonstration of macroreentry and feasibility of operative therapy in the common type of atrial flutter. Am J Cardiol 57:587–591
Saoudi N, Atallah G, Kirkorian G, Touboul P (1990) Catheter ablation of the atrial myocardium in human type I atrial flutter. Circulation 81:762–771
Feld GK, Fleck RP, Chen PS et al (1992) Radiofrequency catheter ablation for the treatment of human type I atrial flutter. Identification of a critical zone in the reentrant circuit by endocardial mapping techniques. Circulation 86:1233–1240
Poty H, Saoudi N, Nair M, Anselme F, Letac B (1996) Further insights into the various types of isthmus block: application to ablation during sinus rhythm. Circulation 94:3204–3213
Jais P, Shah DC, Haissaguerre M, Hocini M, Garrigue S, Metayer PL, Clementy J (2000) Prospective randomized comparison of irrigated-tip versus conventional-tip catheters for ablation of common flutter. Circulation 101:772–776
Tsai CF, Tai CT, Yu WC et al (1999) Is 8-mm more effective than 4-mm tip electrode catheter for ablation of typical atrial flutter? Circulation 100:768–771
Perez FJ, Schubert CM, Parvez B et al (2009) Long-term outcomes after catheter ablation of cavo-tricuspid isthmus dependent atrial flutter: a meta-analysis. Circ Arrhythmia Electrophysiol published online Jun 23, 2009. doi:10.1161/CIRCEP.109.871665
Natale A, Newby K, Pisano E et al (2000) Prospective randomized comparison of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter. J Am Coll Cardiol 35:898–904
Da Costa A, Thevienin J, Roche F et al (2006) 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 114:1676–1681
Babaev A, Suma V, Tita C, Steinberg JS (2003) Recurrence rate of atrial flutter after initial presentation in patients on drug treatment. Am J Cardiol 92:1122–1124
Paydak H, Kall JG, Burke MC et al (1998) Atrial fibrillation after radiofrequency ablation of type I atrial flutter. Circulation 98:315–322
Calkins H, Yong P, Miller JM et al for the Atakr Multicenter Investigators Group (1999) Catheter ablation of accessory pathways, atrioventricular nodal reentrant tachycardia, and the atrioventricular junction: final results of a prospective, multicenter clinical trial. Circulation 99:262–270
Blomström-Lundqvist C, Scheinman MM, Aliot EM et al (2003) ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias–executive summary: a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias). Circulation 108: 1871–1909
Olgin JE, Kalman JM, Saxon LA, Lee RJ, Lesh MD (1997) Mechanism of initiation of atrial flutter in humans: site of unidirectional block and direction of rotation. J Am Coll Cardiol 29:376–384
Huang DT, Monahan KM, Zimetbaum P et al (1998) Hybrid pharmacologic and ablative therapy: a novel and effective approach for the management of atrial fibrillation. J Cardiovasc Electrophysiol 9:462–469
Saoudi N, Cosio F, Waldo A et al (2001) Classification of atrial flutter and regular atrial tachycardia according to electrophysiologic mechanism and anatomic bases: a statement from a joint expert group from the working group of arrhythmias of the European society of cardiology and the North American society of pacing and electrophysiology. J Cardiovasc Electrophysiol 12:852–866
Nakagawa H, Shah N, Matsudaira K et al (2001) Characterization of reentrant circuit in macroreentrant right atrial tachycardia after surgical repair of congenital heart disease: isolated channels between scars allow "focal" ablation. Circulation 103:699–709
Gerstenfeld EP, Marchlinski FE (2007) Mapping and ablation of left atrial tachycardias occurring after atrial fibrillation ablation. Heart Rhythm 4:S65–S72
Jaïs P, Shah DC, Haïssaguerre M et al (2000) Mapping and ablation of left atrial flutters. Circulation 101:2928–2934
Shah D, Sunthorn H, Burri H et al (2006) Narrow, slow-conducting isthmus dependent left atrial reentry developing after ablation for atrial fibrillation: ECG characterization and elimination by focal RF ablation. J Cardiovasc Electrophysiol 17:508–515
Fuster V, Ryden LE, Cannom DS et al (2006) ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to revise the 2001 guidelines for the management of patients with atrial fibrillation). J Am Coll Cardiol 48:e149–246
Lloyd-Jones DM, Wang TJ, Leip EP et al (2004) Lifetime risk for development of atrial fibrillation: the Framingham heart study. Circulation 110:1042–1046
Moe GK, Abildskov JA (1959) Atrial fibrillation as a self-sustaining arrhythmia independent of focal discharge. Am Heart J 58:59–70
Wyse DG, Waldo AL, DiMarco JP et al (2002) Atrial fibrillation follow-up investigation of rhythm management (AFFIRM) investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 347:1825–1833
Van Gelder IC, Hagens VE, Bosker HA et al (2002) Rate control versus electrical cardioversion for persistent atrial fibrillation study group. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 347:1834–1840
Corley SD, Epstein AE, DiMarco JP et al (2004) AFFIRM Investigators. Relationships between sinus rhythm, treatment, and survival in the Atrial fibrillation follow-up investigation of rhythm management (AFFIRM) study. Circulation 109:1509–1513
Roy D, Talajic M, Dorian P et al (2000) Amiodarone to prevent recurrence of atrial fibrillation. Canadian trial of atrial fibrillation investigators. N Engl J Med 342:913–920
Singh BN, Singh SN, Reda DJ et al (2005) Sotalol amiodarone atrial fibrillation efficacy trial (SAFE-T) investigators. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med 352:1861–1872
Scheinman MM, Morady F, Hess DS, Gonzalez R (1982) Catheter-induced ablation of the atrioventricular junction to control refractory supraventricular arrhythmias. JAMA 248:851–855
Kay GN, Ellenbogen KA, Giudici M et al (1998) The ablate and pace trial: a prospective study of catheter ablation of the AV conduction system and permanent pacemaker implantation for treatment of atrial fibrillation. APT investigators. J Interv Card Electrophysiol 2:121–135
Doshi RN, Daoud EG, Fellows C et al (2005) PAVE study group. Left ventricular-based cardiac stimulation post AV nodal ablation evaluation (the PAVE study). J Cardiovasc Electrophysiol 16:1160–1165
Cox JL, Schuessler RB, Lappas DG et al (1996) An 8 ½ year clinical experience with surgery for atrial fibrillation. Ann Surg 224:267–275
Prasad SM, Maniar HS, Camillo CJ et al (2003) The Cox maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures. J Thorac Cardiovasc Surg 126:1822–1828
Swartz JF, Pellersels G, Silvers J et al (1994) A catheter-based curative approach to atrial fibrillation in humans. Circulation 90:I–335
Haissaguerre M, Jais P, Shah DC et al (1996) Right and left atrial radiofrequency catheter therapy of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 7:1132–1144
Jais P, Shah DC, Haissaguerre M et al (1999) Efficacy and safety of septal and left-atrial linear ablation for atrial fibrillation. Am J Cardiol 84:139R–146R
Haissaguerre M, Jais P, Shah DC et al (1998) Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 339:659–666
Chen SA, Hsieh MH, Tai CT et al (1999) Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation 100:1879–1886
Lin WS, Tai CT, Hsieh MH et al (2003) Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy. Circulation 107:3176–3178
Hocini M, Haissaguerre M, Shah D et al (2000) Multiple sources initiating atrial fibrillation from a single pulmonary vein identified by a circumferential catheter. Pacing Clin Electrophysiol 23:1828–1831
Haissaguerre M, Shah DC, Jais P et al (2000) Electrophysiological breakthroughs from the left atrium to the pulmonary veins. Circulation 102:2463–2465
Marchlinski FE, Callans D, Dixit S et al (2003) Efficacy and safety of targeted focal ablation versus PV isolation assisted by magnetic electroanatomic mapping. J Cardiovasc Electrophysiol 14:358–365
Oral H, Knight BP, Tada H et al (2002) Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation 105:1077–1081
Deisenhofer I, Schneider MA, Bohlen-Knauf M et al (2003) Circumferential mapping and electric isolation of pulmonary veins in patients with atrial fibrillation. Am J Cardiol 91:159–163
Marrouche NF, Martin DO, Wazni O et al (2003) Phased-array intracardiac echocardiography monitoring during pulmonary vein isolation in patients with atrial fibrillation: impact on outcome and complications. Circulation 107: 2710–2716
Arentz T, von Rosenthal J, Blum T et al (2003) Feasibility and safety of pulmonary vein isolation using a new mapping and navigation system in patients with refractory atrial fibrillation. Circulation 108:2484–2490
Oral H, Scharf C, Chugh A et al (2003) Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation. Circulation 108:2355–2360
Mansour M, Ruskin J, Keane D (2004) Efficacy and safety of segmental ostial versus circumferential extra-ostial pulmonary vein isolation for atrial fibrillation. J Cardiovasc Electrophysiol 15:532–537
Vasamreddy CR, Lickfett L, Jayam VK et al (2004) Predictors of recurrence followingcatheter ablation of atrial fibrillation using an irrigated-tip ablation catheter. J Cardiovasc Electrophysiol 15:692–697
Pappone C, Rosanio S, Oreto G et al (2000) Circumferential radiofrequency ablation of pulmonary vein ostia: a new anatomic approach for curing atrial fibrillation. Circulation 102:2619–2628
Pappone C, Santinelli V (2004) The who, what, why, and how-to guide for circumferential pulmonary vein ablation. J Cardiovasc Electrophysiol 15:1226–1230
Pappone C, Oreto G, Rosanio S et al (2001) Atrial electroanatomic remodeling after circumferential radiofrequency pulmonary vein ablation: efficacy of an anatomic approach in a large cohort of patients with atrial fibrillation. Circulation 104:2539–2544
Kottkamp H, Tanner H, Kobza R et al (2004) Time courses and quantitative analysis of atrial fibrillation episode number and duration after circular plus linear left atrial lesions: trigger elimination or substrate modification: early or delayed cure? J Am Coll Cardiol 44:869–877
Ouyang F, Baensch D, Ernst S et al (2004) Complete isolation of the left atrium surrounding the pulmonary veins: new insights from the double-lasso technique in paroxysmal atrial fibrillation. Circulation 110:2090–2096
Vasamreddy CR, Dalal D, Eldadah Z et al (2005) Safety and efficacy of circumferential pulmonary vein catheter ablation of atrial fibrillation. Heart Rhythm 2:42–48
Cappato R, Negroni S, Pecora D et al (2003) Prospective assessment of late conduction recurrence across radiofrequency lesions producing electrical disconnection at the pulmonary vein ostium in patients with atrial fibrillation. Circulation 108:1599–1604
Gerstenfeld EP, Callans DJ, Dixit S et al (2003) Incidence and location of focal atrial fibrillation triggers in patients undergoing repeat pulmonary vein isolation: implications for ablation strategies. J Cardiovasc Electrophysiol 14: 685–690
Cheema A, Dong J, Dalal D et al (2007) Incidence and time course of early recovery of pulmonary vein conduction after catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 18:387–391
Jaïs P, Hocini M, Hsu LF et al (2004) Technique and results of linear ablation at the mitral isthmus. Circulation 110:2996–3002
Pappone C, Santinelli V, Manguso F et al (2004) Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation. Circulation 109:327–334
Po SS, Nakagawa H, Jackman WM (2009) Localization of left atrial ganglionated plexi in patients with atrial fibrillation. J Cardiovasc Electrophysiol 20:1186–1189
Nademanee K, McKenzie J, Kosar E et al (2004) A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol 43:2044–2053
Scherr D, Dalal D, Cheema A et al (2009) Long- and short-term temporal stability of complex fractionated atrial electrograms in human left atrium during atrial fibrillation. J Cardiovasc Electrophysiol 20:13–21
Nademanee K, Schwab MC, Kosar EM et al (2008) Clinical outcomes of catheter substrate ablation for high-risk patients with atrial fibrillation J Am Coll Cardiol 51:843–849
Haïssaguerre M, Hocini M, Sanders P et al (2005) Catheter ablation of long-lasting persistent atrial fibrillation: clinical outcome and mechanisms of subsequent arrhythmias. J Cardiovasc Electrophysiol 16:1138–1147
Haïssaguerre M, Sanders P, Hocini M (2005) Catheter ablation of long-lasting persistent atrial fibrillation: critical structures for termination. J Cardiovasc Electrophysiol 16:1125–1137
Scherr D, Dalal D, Chilukuri K et al (2009) Incidence and predictors of left atrial thrombus prior to catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 20:379–384
Valles E, Fan R, Roux JF et al (2008) Localization of atrial fibrillation triggers in patients undergoing pulmonary vein isolation: importance of the carina region. J Am Coll Cardiol 52:1413–1420
Cappato R, Calkins H, Chen SA et al (2005) Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation 111:1100–1105
Holmes DR Jr, Monahan KH, Packer D (2009) Pulmonary vein stenosis complicating ablation for atrial fibrillation: clinical spectrum and interventional considerations. JACC Cardiovasc Interv 2:267–276
Scherr D, Sharma K, Dalal D et al (2009) Incidence and predictors of periprocedural cerebrovascular accident in patients undergoing catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2009 Jun 30. [Epub ahead of print]
Sacher F, Jais P, Stephenson K et al (2007) Phrenic nerve injury after catheter ablation of atrial fibrillation. Indian Pacing Electrophysiol J 7:1–6
Cummings JE, Schweikert RA, Saliba WI et al (2006) Brief communication: atrial-esophageal fistulas after radiofrequency ablation. Ann Intern Med 144:572–574
Cappato R, Calkins H, Chen SA et al (2009) Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation. J Am Coll Cardiol 53:1798–1803
Krittayaphong R, Raungrattanaamporn O, Bhuripanyo K et al (2003) A randomized clinical trial of the efficacy of radiofrequency catheter ablation and amiodarone in the treatment of symptomatic atrial fibrillation. J Med Assoc Thai 86(Suppl 1):S8–S16
Oral H, Pappone C, Chugh A et al (2006) Circumferential pulmonary-vein ablation for chronic atrial fibrillation. N Engl J Med 354:934–941
Wazni OM, Marrouche NF, Martin DO et al (2005) Radiofrequency ablation versus antiarrhythmic drugs as first-line treatment for symptomatic atrial fibrillation. J Am Med Assoc 293:2634–2640
Stabile G, Bertaglia E, Senatore G et al (2006) Catheter ablation treatment in patients with drug-refractory atrial fibrillation: a prospective, multi-centre, randomized, controlled study (Catheter ablation for the cure of atrial fibrillation study). Eur Heart J 27:216–221
Jaïs P, Cauchemez B, Macle L et al (2008) Catheter ablation versus antiarrhythmic drugs for atrial fibrillation: the A4 study. Circulation 118:2498–2505
Pappone C, Augello G, Sala S et al (2006) A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: the APAF (ablation for paroxysmal atrial fibrillation) study. J Am Coll Cardiol 48:2340–2347
Nair GM, Nery PB, Diwakaramenon S et al (2009) A systematic review of randomized trials comparing radiofrequency ablation with antiarrhythmic medications in patients with atrial fibrillation. J Cardiovasc Electrophysiol 20:138–144
Khan MN, Jaïs P, Cummings J et al (2008) PABA-CHF Investigators. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N Engl J Med 359:1778–1785
Calkins H, Reynolds MR, Spector P et al (2009) Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses. Circ Arrhythmia Electrophysiol 2:349–361
Ablation Versus Anti-Arrhythmic (AA) Drug Therapy for AF - Pivotal Trial (CABANA). http://www.clinicaltrials.gov/ct2/show/NCT00911508?term=CABANA&rank=1. Accessed July 6, 2010
Calkins H, Brugada J, Packer DL et al (2007) HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. Heart Rhythm 4: 816–861
Neumann T, Vogt J, Schumacher B et al (2008) Circumferential pulmonary vein isolation with the cryoballoon technique results from a prospective 3-center study. J Am Coll Cardiol 52:273–278
Wazni OM, Barrett C, Martin DO et al (2009) Experience with the Hansen Robotic system for atrial fibrillation ablation- lessons learned and techniques modified: Hansen in the real world. J Cardiovasc Electrophysiol 20:1193–1196
Pappone C, Vicedomini G, Manguso F et al (2006) Robotic magnetic navigation for atrial fibrillation ablation. J Am Coll Cardiol 47:1390–1400
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2011 Springer Science+Business Media, LLC
About this chapter
Cite this chapter
Marine, J.E., Calkins, H. (2011). Catheter Ablation of Atrial Flutter and Atrial Fibrillation. In: Yan, GX., Kowey, P. (eds) Management of Cardiac Arrhythmias. Contemporary Cardiology. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-60761-161-5_9
Download citation
DOI: https://doi.org/10.1007/978-1-60761-161-5_9
Published:
Publisher Name: Humana Press, Totowa, NJ
Print ISBN: 978-1-60761-160-8
Online ISBN: 978-1-60761-161-5
eBook Packages: MedicineMedicine (R0)