Novel Strategies in the Ablation of Typical Atrial Flutter: Role of Intracardiac Echocardiography

Author(s): Gabor Bencsik

Journal Name: Current Cardiology Reviews

Volume 11 , Issue 2 , 2015

Become EABM
Become Reviewer

Graphical Abstract:


Abstract:

Radiofrequency ablation (RFA) of the cavo-tricuspid isthmus (CTI) is one of the most frequently performed procedures in electrophysiology. Despite a high success rate, ablation of the CTI can be unusually difficult in some cases. Multiple tools like angiography, 3D mapping, remote navigation and intracardiac echocardiography (ICE) have been introduced to facilitate typical flutter ablation. This review article summarizes the clinical value of different strategies and tools used for CTI ablation focusing on the importance of approaches utilizing ICE.

Keywords: Atrial flutter, cavo-tricuspid isthmus, fluoroscopy time, intracardiac echocardiography, procedure time, radiofrequency ablation.

[1]
Granada J, Uribe W, Chyou PH, et al. Incidence and predictors of atrial flutter in the general population. J Am Coll Cardiol 2000; 36: 2242-6.
[2]
Babaev A, Suma V, Tita C, Steinberg JS. Recurrence rate of atrial flutter after initial presentation in patients on drug treatment. Am J Cardiol 2003; 92(9): 1122-4.
[3]
Natale A, Newby KH, Pisanó E, et al. Prospective randomized comparison of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter. J Am Coll Cardiol 2000; 35(7): 1898-904.
[4]
Saoudi N, Atallah G, Kirkorian G, Touboul P. Catheter ablation of the atrial myocardium in human type I atrial flutter. Circulation 1990; 81(3): 762-71.
[5]
Feld GK, Fleck RP, Chen PS, et al. Radiofrequency catheter ablation for the treatment of human type 1 atrial flutter. Identification of a critical zone in the reentrant circuit by endocardial mapping techniques. Circulation 1992; 86(4): 1233-40.
[6]
Cosio FG, López-Gil M, Goicolea A, Arribas F, Barroso JL. Radiofrequency ablation of the inferior vena cava-tricuspid valve isthmus in common atrial flutter. Am J Cardiol 1993; 71(8): 705-9.
[7]
Da Costa A, Cucherat M, Pichon N, et al. Comparison of the efficacy of cooled-tip and 8 mm-tip catheters for radiofrequency catheter ablation of the cavo- tricuspid isthmus: Meta-analysis. Pace 2005; 28: 1081-7.
[8]
Hindricks G, Willems S, Kautzner J, et al. Effect of electroanatomically guided versus conventional catheter ablation of typical atrial flutter on the fluoroscopy time and resource use: A prospective randomized multicenter study. J Cardiovasc Electrophysiol 2009; 20: 734-40.
[9]
Calkins H, Canby R, Weiss R, et al. for the 100W Atakr II Investigator Group: Results of catheter ablation of Typical atrial flutter. Am J Cardiol 2004; 94: 437-42.
[10]
Alvarez M, Tercedor L, Herrera N, et al. Cavotricuspid isthmus catheter ablation without the use of fluoroscopy as a first-line treatment. J Cardiovasc Electrophysiol 2011; 22: 656-62.
[11]
Chu E, Fitzpatrick AP, Chin MC, Sudhir K, Yock PG, Lesh MD. Radiofrequency Catheter Ablation Guided by Intracardiac Echocardiography. Circulation 1994; 89: 1301-5.
[12]
Chu E, Kalman JM, Kwasman MA, et al. Intracardiac echocardiography during radiofrequency catheter ablation of cardiac arrhythmias in humans. JACC 1994; 42: 1351-7.
[13]
Dravid SG, Hope B, McKinnie JJ. Intracardiac echocardiography in electrophysiology: a review of current applications in practice. Echocardiography 2008; 25(10): 1172-5.
[14]
Okishige K, Kawabata M, Yamashiro K, et al. Clinical study regarding the anatomical structures of the right atrial isthmus using intra-cardiac echocardiography: Implication for catheter ablation of common atrial flutter. J Interv Card Electrophysiol 2005; 12: 9-12.
[15]
Okumura Y, Watanabe I, Ashino S, et al. Anatomical characteristics of the cavotricuspid isthmus in patients with and without typical atrial flutter: Analysis with two and three-dimensional intracardiac echocardiography. J Interv Card Electrophysiol 2006; 17: 11-9.
[16]
Scaglione M, Caponi D, Di Donna P, et al. Typical atrial flutter ablation outcome: Correlation with isthmus anatomy using intracardiac echo 3D reconstruction. Europace 2004; 6: 407-17.
[17]
Okumura Y, Watanabe I, Ashino S, et al. Electrophysiologic and anatomical characteristics of the right atrial posterior wall in patients with and without atrial flutter:Analysis by intracardiac echocardiography. Circ J 2007; 71: 636-42.
[18]
Tsai CF, Tai CT, Yu WC, et al. Is 8-mm more effective than 4-mm tip electrode catheter for ablation of typical atrial flutter? Circulation 1999; 100(7): 768-71.
[19]
Feld G, Fujimura O, Green U, Mazzola F. Radiofrequency catheter ablation of human type 1 atrial flutter comparison of results with 8 mm versus 4 mm tip ablation catheter. J Am Coll Cardiol 1995; 25: 169A.
[20]
Iesaka Y, Takahashi A, Goya M, et al. High energy radiofrequency catheter ablation for common atrial flutter targeting the isthmus between the inferior vena cava and tricuspid valve annulus using a super long tip electrode. Pace 1998; 21: 401-9.
[21]
Calkins H, Canby R, Weiss R, et al. Results of catheter ablation of Typical atrial flutter. Am J Cardiol 2004; 94: 437-42.
[22]
Schmieder S, Ndrepepa G, Dong J, et al. Acute and long-term results of radiofrequency ablation of common atrial flutter and the influence of the right atrial isthmus ablation on the occurrence of atrial fibrillation. Eur Heart J 2003; 24: 956-62.
[23]
Jais P, Shah DC, Haissaguerre M, et al. Prospective randomized comparison of irrigated-tip versus conventional-tip catheters for ablation of common flutter. Circulation 2000; 101: 772-6.
[24]
Da Costa A, Cucherat M, Pichon N, et al. K: Comparison of the efficacy of cooled-tip and 8 mm-tip catheters for radiofrequency catheter ablation of the cavo-tricuspid isthmus: Meta-analysis. Pace 2005; 28: 1081-7.
[25]
Da Costa A, Jamon Y, Romeyer-Bouchard C, Thévenin J, Messier M, Isaaz K. Catheter selection for ablation of the cavotricuspid isthmus for treatment of typical atrial flutter. J Interv Card Electrophysiol 2006; 17(2): 93-101.
[26]
Lewalter T, Weiss C, Spencker S, et al. Gold vs. platinum-iridium tip catheter for cavotricuspid isthmus ablation: the AURUM 8study. Europace 2011; 13(1): 102-8.
[27]
Feld GK, Daubert JP, Weiss R, Miles WM, Pelkey W. Cryoablation Atrial Flutter Efficacy Trial Investigators Acute and long-term efficacy and safety of catheter cryoablation of the cavotricuspid isthmus for treatment of type 1 atrial flutter. Heart Rhythm 2008; 5(7): 1009-14.
[28]
Matsuo S, Yamane T, Tokuda M, et al. Prospective randomized comparison of a steerable versus a non-steerable sheath for typical atrial flutter ablation. Europace 2010; 12(3): 402-9.
[29]
Kirchhof P, Ozgün M, Zellerhoff S, et al. Diastolic isthmus length and ‘vertical’ isthmus angulation identify patients with difficult catheter ablation of typical atrial flutter: a pre-procedural MRI study. Europace 2009; 11(1): 42-7.
[30]
Chen JY, Lin KH, Liou YM, Chang KC, Huang SK. Usefulness of pre-procedure cavotricuspid isthmus imaging by modified transthoracic echocardiography for predicting outcome of isthmus- dependent atrial flutter ablation. J Am Soc Echocardiogr 2011; 24(10): 1148-55.
[31]
Knecht S, Castro-Rodriguez J, Verbeet T, et al. Multidetector 16-slice CT scan evaluation of cavotricuspid isthmus anatomy before radiofrequency ablation. J Interv Card Electrophysiol 2007; 20(1-2): 29-35.
[32]
Heidbüchel H, Willems R, Van Rensburg H, Adams J, Ector H, Van de Werf F. Right atrial angiographic evaluation of the posterior isthmus. Relevance for ablation of typical atrial flutter. Circulation 2000; 101: 2178-84.
[33]
Cabrera JA, Sanchez-Quintana D, Ho SY, Medina A, Anderson RH. The architecture of the atrial musculature between the orifice of the inferior caval vein and the tricuspid valve: The anatomy of the isthmus. J Cardiovasc Electrophysiol 1998; 9: 1186-95.
[34]
Wang Z, Jorge A, Jo W, et al. Anatomic variability of the human eustachian ridge. Pacing Clin Electrophysiol 1996; 19(part II): 724.
[35]
Da Costa A, Faure E, Thevenin J, et al. Effect of isthmus anatomy and ablation catheter on radiofrequency catheter ablation of the cavotricuspid isthmus. Circulation 2004; 110: 1030-5.
[36]
Da Costa A, Romeyer-Bouchard C, Dauphinot V, et al. Cavotricuspid isthmus angiography predicts atrial flutter ablation efficacy in 281 patients randomized between 8 mm- and externally irrigated-tip catheter. Eur Heart J 2006; 27(15): 1833-40.
[37]
Kottkamp H, Hugl B, Krauss B, Wetzel U, Fleck A, Schuler G. Electromagnetic versus fluoroscopic mapping of the inferior isthmus for ablation of typical atrial flutter: A prospective randomised study. Circulation 2000; 102: 2082-6.
[38]
Hindricks G, Willems S, Kautzner J, et al. Effect of electroanatomically guided versus conventional catheter ablation of typical atrial flutter on the fluoroscopy time and resource use: A prospective randomized multicenter study. J Cardiovasc Electrophysiol 2009; 20: 734-40.
[39]
Álvarez M, Tercedor L, Herrera N, Muñoz L, Galdeano RS, Valverde F. Cavotricuspid isthmus catheter ablation without the use of fluoroscopy as a first-line treatment. J Cardiovasc Electrophysiol 22(6): 656-62.
[40]
Arya A, Kottkamp H, Piorkowski C, et al. Initial clinical experience with a remote magnetic catheter navigation system for ablation of cavotricuspid isthmus-dependent right atrial flutter. Pacing Clin Electrophysiol 2008; 31(5): 597-603.
[41]
Vollmann D, Lüthje L, Seegers J, Hasenfuss G, Zabel M. Remote magnetic catheter navigation for cavotricuspid isthmus ablation in patients with common-type atrial flutter. Circ Arrhythm Electrophysiol 2009; 2(6): 603-10.
[42]
Steven D, Rostock T, Servatius H, et al. Robotic versus conventional ablation for common-type atrial flutter: a prospective randomized trial to evaluate the effectiveness of remote catheter navigation. Heart Rhythm 2008; 5(11): 1556-60.
[43]
Regoli F, Faletra FF, Nucifora G, et al. Feasibility and acute efficacy of radiofrequency ablation of cavotricuspid isthmus-dependent atrial flutter guided by real- time 3D TEE. JACC Cardiovasc Imaging 2010; 4: 716-26.
[44]
Redfearn DP, Skanes AC, Gula LJ, Krahn AD, Yee R, Klein GJ. Cavotricuspid isthmus conduction is dependent on underlying anatomic bundle architecture: observations using a maximum voltage-guided ablation technique. J Cardiovasc Electrophysiol 2006; 17(8): 832-8.
[45]
Gula LJ, Redfearn DP, Veenhuyzen GD, et al. Reduction in atrial flutter ablation time by targeting maximum voltage: results of a prospective randomized clinical trial. J Cardiovasc Electrophysiol 2009; 20(10): 1108-12.
[46]
Subbiah RN, Gula LJ, Krahn AD, et al. Rapid ablation for atrial flutter by targeting maximum voltagefactors associated with short ablation times. J Cardiovasc Electrophysiol 2007; 18: 612-6.
[47]
Bauernfeind T, Kardos A, Foldesi C, Mihalcz A, Abraham P. Szili- Torok T. Assessment of the maximum voltage-guided technique for cavotricuspid isthmus ablation during ongoing atrial flutter. J Interv Card Electrophysiol 2007; 19: 195-9.
[48]
Posan E, Redfearn DP, Gula LJ, et al. Elimination of cavotricuspid isthmus conduction by a single ablation lesion: Observations from a maximum voltage-guided ablation technique. Europace 2007; 9: 208-11.
[49]
Lewalter T, Lickfett L, Weiss C, et al. “Largest amplitude ablation” is the optimal approach for typical atrial flutter ablation: a subanalysis from the AURUM 8 study. J Cardiovasc Electrophysiol 2012; 23(5): 479-85.
[50]
Olgin JE, Kalman JM, Fitzpatrick AP, Lesh MD. 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 1995; 92(7): 1839-48.
[51]
Kalman JM, Olgin JE, Saxon LA, Fisher WG, Lee RJ, Lesh MD. Activation and entrainment mapping defines the tricuspid annulus as the anterior barrier in typical atrial flutter. Circulation 1996; 94(3): 398-406.
[52]
Darbar D, Olgin JE, Miller JM, Friedman PA. Localization of the origin of arrhythmias for ablation: from Electrocardiography to advanced endocardial mapping systems. J Cardiovasc Electrophysiol 2001; 12(11): 1309-25.
[53]
Morton JB, Sanders P, Davidson NC, Sparks PB, Vohra JK, Kalman JM. Phased- array intracardiac echocardiography for defining cavotricuspid isthmus anatomy during radiofrequency ablation of typical atrial flutter. J Cardiovasc Electrophysiol 2003; 14: 591-7.
[54]
Pap R, Klausz G, Gallardo R, Sághy L. Intracardiac echocardiography in a case with previous failed cavotricuspid isthmus ablation. J Interv Card Electrophysiol 2009; 26: 119-20.
[55]
Bencsik G, Pap R, Sághy L. Intracardiac echocardiography for visualization of the Eustachian valve during radiofrequency ablation of typical atrial flutter. Europace 2009; 11: 901.
[56]
Bencsik G, Pap R, Makai A, et al. Randomized trial of intracardiac echocardiography during cavotricuspid isthmus ablation. J Cardiovasc Electrophysiol 2012; 23(9): 996-1000.
[57]
Ilg KL, Kuhne M, Crawford T, et al. Randomized comparison of cavotricuspid isthmus ablation for atrial flutter using an open irrigationtip versus a large-tip radiofrequency ablation catheter. J Cardiovasc Electrophysiol 2011; 22: 1007-12.


Rights & PermissionsPrintExport Cite as

Article Details

VOLUME: 11
ISSUE: 2
Year: 2015
Page: [127 - 133]
Pages: 7
DOI: 10.2174/1573403X10666141013121843
Price: $65

Article Metrics

PDF: 22
HTML: 2
EPUB: 1
PRC: 1