Flutter ablation alone is not enough
MUNCIE, INDIANA. There is ample evidence that right atrial flutter and atrial fibrillation (AF) often coexist in the same patient. Although the patient may only have symptoms of one of the arrhythmias, the accompanying arrhythmia may be unmasked if the originally symptomatic arrhythmia is successfully dealt with. It is therefore fairly common practice to perform a right atrial flutter ablation or cavotricuspid isthmus (CTI) ablation after a pulmonary vein isolation (PVI) procedure in order to avoid a repeat to deal with possibly unmasked flutter.

A group of researchers at the Ball Memorial Hospital now reports that routinely performing a PVI procedure in combination with a CTI ablation in patients originally diagnosed with right atrial flutter only is safe and effective and reduces the incidence of any arrhythmia being present after follow-up (16 months in this study) by 43%. The study included 48 patients diagnosed with typical right atrial flutter as their sole arrhythmia. The average age was 56 years and 90% of the patients were male. They were randomized to receive a CTI ablation on its own (25 patients) or the CTI plus a circumferential, anatomically-guided PVI procedure (23 patients). Six patients in the CTI + PVI group also underwent a step-wise protocol consisting of ablation of complex fractionated electrograms, creation of a left atrial roof line and other lesions as necessary. Follow-up included monthly ECGs and 48-hour Holter monitoring every two months.

After an average follow-up of 16 months, all patients were free of flutter episodes, once again proving that a right atrial flutter ablation is safe and usually highly successful. However, in the CTI ablation group only 44% of patients were arrhythmia-free as 56% had developed AF following their flutter ablation – most doing so within the first year following their procedure. In contrast, in the CTI + PVI ablation group, not only were all patients free of flutter, but 87% were also free of AF (without medication) at the end of follow-up. The researchers conclude that undergoing a PVI procedure at the time of a CTI ablation results in significantly better long-term freedom from any arrhythmia.

Navarrete, A, et al. Ablation of atrial fibrillation at the time of cavotricuspid isthmus ablation in patients with atrial flutter without documented atrial fibrillation derives a better long-term benefit. Journal of Cardiovascular Electrophysiology, Vol. 22, January 2011, pp. 34-38

Editor's comment: Several of our surveys have shown that undergoing a right atrial flutter ablation on its own does not eliminate or even reduce the symptoms of coexisting AF. This, combined with the results of the above study, clearly supports the contention that CTI and PVI procedures should be combined in order to achieve the greatest chance of an arrhythmia-free future.