Crucial Role of Pulmonary Vein Firing As an Initiator of Typical Atrial Flutter: Evidence of a Close Relationship Between Atrial Fibrillation and Typical Atrial Flutter

Overview

Journal J Arrhythm

Publisher Wiley

Date 2017 Apr 19

PMID 28416972

Citations 3

Authors

Takashi Kaneshiro

Kentaro Yoshida

Yukio Sekiguchi

Hiroshi Tada

Kenji Kuroki

Keisuke Kuga

Yoshiyuki Kamiyama

Hitoshi Suzuki

Yasuchika Takeishi

Kazutaka Aonuma

Affiliations

Soon will be listed here.

Abstract

Background: Several studies reported that cavotricuspid isthmus-dependent atrial flutter (typical AFL) frequently coexists with atrial fibrillation (AF); however, the underlying mechanisms have not been fully investigated. This study aimed to reveal the mechanisms of the initiation of typical AFL and the association between typical AFL and AF.

Methods: Among 154 consecutive patients undergoing a first catheter ablation of AF, we investigated the appearance and mechanism of spontaneous initiation of typical AFL during catheter ablation. Then, we retrospectively investigated 67 consecutive patients without a previous AF episode who underwent typical AFL ablation. The occurrence and predictors of AF after catheter ablation were evaluated.

Results: During AF ablation, spontaneous initiation of typical AFL occurred during sinus rhythm in eight (5.2%) patients. The initiations of typical AFL were pulmonary vein (PV) firings except in one patient, in whom paroxysmal AF following superior vena cava firing initiated reverse typical AFL after PV isolation. After typical AFL ablation, AF occurred in 23 (34.3%) patients (mean follow up, 28.2±20.3 months). Kaplan-Meier analysis showed the occurrence of AF after typical AFL ablation to be significantly higher in the patients with a larger left atrial diameter over 40 mm (log-rank test, =0.046).

Conclusions: PV firing through AF played an important role in initiating typical AFL. The occurrence of AF after typical AFL ablation was high, and a dilated left atrium was associated with increased occurrence of AF. These findings disclosed the close relationship between typical AFL and AF, especially PV firing.

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References

Schneider R, Lauschke J, Tischer T, Schneider C, Voss W, Moehlenkamp F . Pulmonary vein triggers play an important role in the initiation of atrial flutter: Initial results from the prospective randomized Atrial Fibrillation Ablation in Atrial Flutter (Triple A) trial. Heart Rhythm. 2015; 12(5):865-71. DOI: 10.1016/j.hrthm.2015.01.040. View

Bertaglia E, Zoppo F, Bonso A, Proclemer A, Verlato R, Coro L . Long term follow up of radiofrequency catheter ablation of atrial flutter: clinical course and predictors of atrial fibrillation occurrence. Heart. 2003; 90(1):59-63. PMC: 1768035. DOI: 10.1136/heart.90.1.59. View

Hsieh M, Tai C, Tsai C, Yu W, Lin W, Huang J . Mechanism of spontaneous transition from typical atrial flutter to atrial fibrillation: role of ectopic atrial fibrillation foci. Pacing Clin Electrophysiol. 2001; 24(1):46-52. DOI: 10.1046/j.1460-9592.2001.00046.x. View

Moreira W, Timmermans C, Wellens H, Mizusawa Y, Philippens S, Perez D . Can common-type atrial flutter be a sign of an arrhythmogenic substrate in paroxysmal atrial fibrillation? Clinical and ablative consequences in patients with coexistent paroxysmal atrial fibrillation/atrial flutter. Circulation. 2007; 116(24):2786-92. DOI: 10.1161/CIRCULATIONAHA.107.711622. View

Mohanty S, Mohanty P, Di Biase L, Bai R, Santangeli P, Casella M . Results from a single-blind, randomized study comparing the impact of different ablation approaches on long-term procedure outcome in coexistent atrial fibrillation and flutter (APPROVAL). Circulation. 2013; 127(18):1853-60. DOI: 10.1161/CIRCULATIONAHA.113.001855. View

Waldo A, Feld G . Inter-relationships of atrial fibrillation and atrial flutter mechanisms and clinical implications. J Am Coll Cardiol. 2008; 51(8):779-86. DOI: 10.1016/j.jacc.2007.08.066. View

Tai C, Chen S, Chiang C, Lee S, Ueng K, Wen Z . Characterization of low right atrial isthmus as the slow conduction zone and pharmacological target in typical atrial flutter. Circulation. 1997; 96(8):2601-11. DOI: 10.1161/01.cir.96.8.2601. View

Kistler P, Sanders P, Hussin A, Morton J, Vohra J, Sparks P . Focal atrial tachycardia arising from the mitral annulus: electrocardiographic and electrophysiologic characterization. J Am Coll Cardiol. 2003; 41(12):2212-9. DOI: 10.1016/s0735-1097(03)00484-4. View

Kistler P, Sanders P, Fynn S, Stevenson I, Hussin A, Vohra J . Electrophysiological and electrocardiographic characteristics of focal atrial tachycardia originating from the pulmonary veins: acute and long-term outcomes of radiofrequency ablation. Circulation. 2003; 108(16):1968-75. DOI: 10.1161/01.CIR.0000095269.36984.75. View

10.

Gilligan D, Zakaib J, Fuller I, Shepard R, Dan D, Wood M . Long-term outcome of patients after successful radiofrequency ablation for typical atrial flutter. Pacing Clin Electrophysiol. 2003; 26(1 Pt 1):53-8. DOI: 10.1046/j.1460-9592.2003.00150.x. View

11.

Calkins H, Canby R, Weiss R, Taylor G, Wells P, Chinitz L . Results of catheter ablation of typical atrial flutter. Am J Cardiol. 2004; 94(4):437-42. DOI: 10.1016/j.amjcard.2004.04.058. View

12.

Haissaguerre M, Jais P, Shah D, Takahashi A, Hocini M, Quiniou G . Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998; 339(10):659-66. DOI: 10.1056/NEJM199809033391003. View

13.

Lin W, Tai C, Hsieh M, Tsai C, Lin Y, Tsao H . Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy. Circulation. 2003; 107(25):3176-83. DOI: 10.1161/01.CIR.0000074206.52056.2D. View

14.

Wazni O, Marrouche N, Martin D, Gillinov A, Saliba W, Saad E . Randomized study comparing combined pulmonary vein-left atrial junction disconnection and cavotricuspid isthmus ablation versus pulmonary vein-left atrial junction disconnection alone in patients presenting with typical atrial flutter and atrial.... Circulation. 2003; 108(20):2479-83. DOI: 10.1161/01.CIR.0000101684.88679.AB. View

15.

Shimizu A, Nozaki A, Rudy Y, Waldo A . Onset of induced atrial flutter in the canine pericarditis model. J Am Coll Cardiol. 1991; 17(5):1223-34. DOI: 10.1016/0735-1097(91)90857-6. View

16.

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(13):1517-22. DOI: 10.1161/01.cir.102.13.1517. View

17.

Da Costa A, Romeyer C, Mourot S, Messier M, Cerisier A, Faure E . Factors associated with early atrial fibrillation after ablation of common atrial flutter. A single centre prospective study. Eur Heart J. 2002; 23(6):498-506. DOI: 10.1053/euhj.2001.2819. View

18.

Chyou J, Hickey K, Diamond L, Whang W, Dizon J, Garan H . Atypical electrocardiographic features of cavotricuspid isthmus-dependent atrial flutter occurring during left atrial fibrillation ablation. Ann Noninvasive Electrocardiol. 2010; 15(3):200-8. PMC: 6931972. DOI: 10.1111/j.1542-474X.2010.00364.x. View

19.

Waldo A, Cooper T . Spontaneous onset of type I atrial flutter in patients. J Am Coll Cardiol. 1996; 28(3):707-12. DOI: 10.1016/0735-1097(96)00223-9. View

20.

Tai C, Chen S, Chiang C, Lee S, Wen Z, Huang J . Long-term outcome of radiofrequency catheter ablation for typical atrial flutter: risk prediction of recurrent arrhythmias. J Cardiovasc Electrophysiol. 1998; 9(2):115-21. DOI: 10.1111/j.1540-8167.1998.tb00892.x. View