cavotricuspid isthmus ablation

Romanov A, Pokushalov E, Bayramova S, Ponomarev D, Shabanov V, Losik D, Stenin I, Elesin D, Mikheenko I, Steinberg JS. Magnano AR, Argenziano M, Dizon JM, Vigilance D, Williams M, Yegen H et al. In some individuals this pouch can be prominent, particularly near the septum. IBM SPSS Statistics software version 23 (IBM Corporation, Armonk, NY, USA) was used for statistical analysis. Although RF catheter ablation is a safe and effective procedure for AFL treatment, CTI anatomic complexity can affect ablation parameters and outcome. After multivariable adjustment, however, only CTI ablation and smaller left atrial volume index were significant predictors of freedom from ATa recurrence. Pulmonary Vein Isolation to Reduce Future Risk of Atrial Fibrillation in Patients Undergoing Typical Flutter Ablation: Results from a Randomized Pilot Study (REDUCE AF). Romero J, Diaz JC, Di Biase L, Kumar S, Briceno D, Tedrow UB, Valencia CR, Baldinger SH, Koplan B, Epstein LM, John R, Michaud GF, Stevenson WG. The full text of this article hosted at iucr.org is unavailable due to technical difficulties. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. The bidirectional block of the CTI was confirmed in all patients, and there were no complications related to CTI ablation. Tel: +82-2-34103419; fax: +82-2-34103849; e-mail: Relationship between atrial fibrillation and typical atrial flutter in humans: activation sequence changes during spontaneous conversion, Inter-relationships between atrial flutter and atrial fibrillation, Risk of atrial fibrillation after atrial flutter ablation: impact of AF history, gender, and antiarrhythmic drug medication, Incidence of new-onset atrial fibrillation after cavotricuspid isthmus ablation for atrial flutter, 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, 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society, 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, Surgical vs. transcatheter pulmonary vein isolation as first invasive treatment in patients with atrial fibrillation: a matched group comparison, Pulmonary vein isolation to reduce future risk of atrial fibrillation in patients undergoing typical flutter ablation: results from a randomized pilot study (REDUCE AF), Atrial fibrillation ablation: importance of cavotricuspid isthmus block, Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis, Treatment of stand-alone atrial fibrillation with a right thoracoscopic approach employing a microwave or monopolar radiofrequency energy source: long-term results, Long-term results of surgical minimally invasive pulmonary vein isolation for paroxysmal lone atrial fibrillation, Mechanisms of atrial tachyarrhythmias following surgical atrial fibrillation ablation, Management of recurrent atrial arrhythmias after minimally invasive surgical pulmonary vein isolation and ganglionic plexi ablation for atrial fibrillation, Management of refractory atrial fibrillation post surgical ablation, Meta-analysis of ablation of atrial flutter and supraventricular tachycardia, Cost-effectiveness of the convergent procedure and catheter ablation for non-paroxysmal atrial fibrillation, Hybrid ablation for atrial fibrillation: a systematic review, Prolonged rhythm monitoring for the detection of occult paroxysmal atrial fibrillation in ischemic stroke of unknown cause. A total of 63 patients with CTI ablation and 91 patients without CTI ablation were analysed. To compare the outcomes of patients who underwent PVI alone vs. PVI + prophylactic CTI ablation. 1 The CTI is a well-defined quadrilateral-shaped anatomic area, bordered by the tricuspid valve (TV) anteriorly and the eustachian valve and eustachian ridge (ER) posteriorly. Introduction. Propensity score (PS) matching analysis based on a registry dataset of 1931 consecutive patients who underwent a first AF catheter ablation. Electrophysiological anatomy of typical atrial flutter: the posterior boundary and causes for difficulty with ablation. In addition to CTI ablation, additional PV antral ablation was included in the Cox regression model because PV reconnection is known to be one of the most important causes of recurrent ATa after surgical ablation of AF [15, 16]. CTI = cavotricuspid isthmus; IVC = inferior vena cava; RCA = right coronary artery; SCV = small cardiac vein. Patients were monitored for the first 24 h in the intensive care unit. Epub 2017 Jan 9. Supported by the Registry for Cardio-cerebro-vascular Pathology, Veneto Region, Venice, Italy. PV potentials were checked in 33 (52.4%) patients among the 63 patients in the CTI ablation group, and 11 patients showing residual PV potentials underwent additional PV antral ablation.  |  En, Recent studies also showed that many patients diagnosed with AFL develop AF after catheter ablation of AFL [3–5]. Conversely, one previous study showed that CTI ablation significantly reduced the inducibility of ATa after catheter ablation of AF [10]. Roithinger FX, Karch MR, Steiner PR, SippensGroenewegen A, Lesh MD. As an additional procedure with TTA, however, time and cost may be a concern when employing a staged approach associated with catheter ablation. NLM Advancement of the ablation catheter into the SCV for ablation in the epicardial aspect of the CTI for creation of a transmural lesion can be considered in refractory cases (. CS = coronary sinus; CT = crista terminalis; EP = Eustachian pouch; ER = Eustachian ridge; FO = foramen ovale; IVC = inferior vena cava; P = pectinate muscles; TV = tricuspid valve. Acute procedure failure or major complications occurred in 3 cases, all with complex CTI anatomy. 2). Once all ablations were completed and the conduction block was confirmed, the left atrial auricle was removed with an endoscopic stapling device. Get the latest research from NIH: https://www.nih.gov/coronavirus. An intracardiac echocardiography catheter (ICE; ACUNAV, Siemens, Mountain View, CA) was inserted through the right femoral vein (, Below, we discuss common anatomic variants that can interfere with CTI ablation and their applicability in our case (, Ablation line more laterally than usual position, Use of an irrigated ablation catheter and/or contact force–sensing catheters, Circular ablation to isolate the pouch and anchoring to the IVC and tricuspid annulus, Ablation line more medially than usual position, Arching the ablation catheter to prevent contact with the Eustachian ridge, Ablation line more laterally away from the SCV, Temporary obstruction of SCV ostium with a catheter or angioplasty balloon. Note that a prominent SCV is present in. Working off-campus? Maintenance of atrial fibrillation (AF) depends on the presence of multiple reentrant circuits in the atria. https://doi.org/10.1016/j.hrthm.2019.05.030. Radiofrequency ablation was performed under anatomic and electrogram guidance. Conclusion. A randomized trial of contact force in atrial flutter ablation. Take an interactive quiz related to this article: © 2019 Heart Rhythm Society. Anderson LH, Black EJ, Civello KC, Martinson MS, Kress DC. Atrial fibrillation; Cavotricuspid isthmus; Prognosis; Pulmonary vein isolation; Radiofrequency catheter ablation.  |  The purpose of this study was to see whether performing on-line ablation has similar clinical results compared to the conventional strategy. The Eustachian ridge divides the CTI into an anterior sub-Eustachian portion between the Eustachian ridge and the tricuspid annulus, and a more posterior portion leading from the ridge to the anterior border of the IVC. We believe that this study drives the need for further investigations into cost-effectiveness and patient selection for this strategy. However, certain aspects of the regional anatomy can pose technical challenges such that bidirectional block across the CTI can be difficult to achieve. PS analysis yielded a study population of 822 matched patients (58 ± 11 years, 69% males, 64% with paroxysmal AF). [The effects of the ablation of atrial flutter in patients with and without a clinical history of paroxysmal atrial fibrillation]. Prospective use of ablation index for the ablation of right ventricle outflow tract premature ventricular contractions: a proof of concept study. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error, [Article in 2017 Apr;48(3):307-315. doi: 10.1007/s10840-016-0211-9. Intramural coronary vasculature prevents transmural radiofrequency lesion formation: implications for linear ablation. Correlative anatomy and electrophysiology for the interventional electrophysiologist: right atrial flutter. Unlike catheter ablation, little is known about the benefits of cavotricuspid isthmus (CTI) ablation in total thoracoscopic ablation (TTA) of atrial fibrillation (AF). The Kaplan–Meier curves showing freedom from recurrent atrial tachyarrhythmia. Patients were considered to have indeterminate recurrence in the presence of missing 24-h Holter monitoring measurements and no symptoms or 12-lead electrocardiograms suggestive of recurrence. In the case of CTI ablation, the distal right coronary artery (RCA) and small cardiac vein (SCV) run on the epicardial aspect of the CTI and may cause a “heat sink” effect. The CTI ablation group showed a significantly higher survival rate free from recurrent ATa than that of the non-CTI ablation group at 5 years (52.5% vs 41.4%, P = 0.046). The recognition of these variations, primarily with the use of intraprocedural ICE, is critical in developing effective and safe troubleshooting approaches. Evaluation of an individualized strategy of cavotricuspid isthmus ablation as an adjunct to atrial fibrillation ablation. This site needs JavaScript to work properly. Altman RK, Proietti R, Barrett CD, Paoletti Perini A, Santangeli P, Danik SB et al. Mohanty S, Natale A, Mohanty P, DI Biase L, Trivedi C, Santangeli P, Bai R, Burkhardt JD, Gallinghouse GJ, Horton R, Sanchez JE, Hranitzky PM, Al-Ahmad A, Hao S, Hongo R, Beheiry S, Pelargonio G, Forleo G, Rossillo A, Themistoclakis S, Casella M, Russo AD, Tondo C, Dixit S. J Cardiovasc Electrophysiol. Baman JR, Kaplan RM, Diaz CL, Peigh G, Bavishi AA, Trivedi A, Wasserlauf J, Chicos AB, Arora R, Kim S, Lin A, Verma N, Knight BP, Passman RS. In patients with cavotricuspid isthmus (CTI)-dependent atrial flutter, ablation along the CTI is often a routine and straightforward procedure. Flow chart of the study population. There was no difference in the baseline characteristics between the CTI ablation and non-CTI ablation groups, except for a higher proportion of male patients in the CTI ablation group (98.4% vs 89.0%, P = 0.03) (Table 1). Epub 2017 Jan 9. Total thoracoscopy was defined as a video-assisted thoracoscopic surgical technique without the aid of a Da Vinci system and cardiopulmonary bypass. Ablation along the CTI terminated the flutter. First-in-children epicardial mapping of the heart: unravelling arrhythmogenesis in congenital heart disease, Development of a porcine model of emergency resternotomy at a low-volume cardiac surgery centre, Donor risk analysis and validation in heart transplants: a single-centre experience, Assessing palliative care need in left ventricular assist device patients and heart transplant recipients, A recurrent lung abscess caused by delayed diagnosis of unique co-infection with, About Interactive CardioVascular and Thoracic Surgery, About the European Association for Cardio-Thoracic Surgery, About the European Board of Cardiovascular Perfusion, https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model, Receive exclusive offers and updates from Oxford Academic. We use cookies to help provide and enhance our service and tailor content and ads. Role of the tricuspid annulus and the eustachian valve/ridge on atrial flutter. AFL is often preceded by AF, and sometimes AF is converted to AFL by Class 1c antiarrhythmic drugs. The remainder of the RF lesion forms from conductive heating of adjacent myocardial tissue. Tissue edema from initial inadequate ablation lesions can hamper subsequent successful ablation lesions in the same locations during the same procedure. Presented at the Annual Meeting of the European Heart Rhythm Association Congress, Barcelona, Spain, 19 March 2018. Three (10%) were non-inducible. PVI is a well-established therapy for patients with drug refractory atrial fibrillation (AF). Radiofrequency energy was applied using an irrigated catheter with maximum power of 30 W until PV isolation or bidirectional block of CTI was confirmed. A fluoroscopic image merged with a 3-dimensional image of the reconstructed right atrium shows the catheter positions and point-by-point ablation lesions in cavotricuspid isthmus (B). It should be noted that the SCV may be very small or absent in many patients, therefore not allowing cannulation with a standard ablation catheter. The primary outcome was survival rate free from ATa recurrence. A lateral ablation line was carried from the tricuspid annulus to the IVC and bidirectional block was demonstrated with pacing maneuvers medially and laterally to the ablation line.  |  Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. Europace. The additional price of CTI ablation may be offset by the lower recurrence rate, making additional CTI ablation cost-effective compared with TTA alone as shown in a recent study on the cost-effectiveness of a hybrid ablation procedure [18]. Introduction and objective: The CTI ablation group showed significantly higher survival rates free from recurrent ATa than that of the non-CTI ablation group (88.9% vs 72.9%, P = 0.02 at 1 year; 73.3% vs 60.1% at 3 years, P = 0.08; 52.5% vs 41.4%, P = 0.046 at 5 years) (Fig. Please enable it to take advantage of the complete set of features! COVID-19 is an emerging, rapidly evolving situation.  |  There are no established guidelines for indication, approach or lesion sets of the procedure. By continuing you agree to the Use of Cookies. and you may need to create a new Wiley Online Library account. All rights reserved. 2013 Jul;24(7):742-51. doi: 10.1111/jce.12121. A prior study of ablation of epicardial accessory pathways in the posteroseptal region reported that coronary injury happened in 50% of cases when RF was performed within 2 mm from the artery. HHS J Cardiovasc Electrophysiol. Epicardial thoracoscopic ablation versus endocardial catheter ablation for management of atrial fibrillation: a systematic review and meta-analysis, Right mini-thoracotomy for left maze with transesophageal echo guidance, Minimally invasive thoracoscopic hybrid treatment of lone atrial fibrillation: early results of monopolar versus bipolar radiofrequency source, Copyright © 2020 European Association for Cardio-Thoracic Surgery. Echocardiographic data were not available in 6 patients (n = 4, CTI ablation group; n = 2, non-CTI ablation group). The interindividual anatomic variability can influence the duration and outcome of ablation procedure. Kron J, Kasirajan V, Wood MA, Kowalski M, Han FT, Ellenbogen KA. For CTI ablation, a duodecapolar catheter was placed in the right atrium and coronary sinus to record atrial signals and confirm bidirectional block of CTI after ablation. Relevance to catheter ablation of the septal isthmus and a new technique for rapid identification of ablation success. Prophylactic CTI ablation at the time of a first PVI does not seem to improve long-term freedom from AF. Standard definition of CTI morphologic variants is recommended. Female gender, current smoking, indexed LA volume and non-paroxysmal AF were identified as independent predictors of relapse after matching. Wazni O, Marrouche NF, Martin DO, Gillinov AM, Saliba W, Saad E, Klein A, Bhargava M, Bash D, Schweikert R, Erciyes D, Abdul-Karim A, Brachman J, Gunther J, Pisano E, Potenza D, Fanelli R, Natale A. Atrial arrhythmia inducibility was tested with burst pacing down to 150 ms or atrial refractoriness from the proximal coronary sinus. A 68-year-old man with history of treated hypertension and hyperlipidemia presented with episodic palpitations and shortness of breath. 2018 Jun;29(6):872-878. doi: 10.1111/jce.13485. AF: atrial fibrillation; CTI: cavotricuspid isthmus; RFA: radiofrequency ablation; TTA: total thoracoscopic ablation. The role of adenosine following pulmonary vein isolation in patients undergoing catheter ablation for atrial fibrillation: a systematic review. J Cardiovasc Electrophysiol. Ablation of the cavotricuspid isthmus (CTI) for the treatment of atrial flutter (AFL) has become standard practice. PV isolation was achieved by endocardial touch-up in 11 patients in this study. However, it remains unclear whether prophylactic cavotricuspid isthmus (CTI) ablation at the time of PVI improves long-term freedom from AF. He was unable to tolerate medications; therefore an electrophysiologic study and ablation was recommended. Before discharge after TTA, confirmation of PV isolation or catheter-based endocardial ablation was performed for selected patients. Values are reported as mean ± standard deviation or n (%). The relationship between AFL and AF has been established for many years. Although TTA overcomes the high invasiveness of the maze operation and is known to be comparable with catheter ablation in AF recurrence [8], it has a disadvantage when it comes to CTI ablation. This might affect the results of this study, but the same limitation is inherent in previous studies using various rhythm monitoring methods and different definitions of success. Background— Despite the success of catheter ablation of cavotricuspid isthmus–dependent atrial flutter (AFL), important postablation outcomes are ill-defined. 2003 Nov 18;108(20):2479-83. doi: 10.1161/01.CIR.0000101684.88679.AB. Published by Elsevier B.V. NLM A pouchlike recess of the CTI was present in 9.6% of autopsy hearts. Our results may not represent all the AF patients undergoing TTA because of differences in study populations, ablation techniques and surgical skills. Epub 2003 Nov 10. Drs Baccillieri and Rizzo contributed equally to this work. A more lateral ablation line can be performed that increases the distance from the medial portion of the SCV where the vessel has a large caliber. Because the detection of intermittent AF depends on the type and the timing of cardiac monitoring, longer-term monitoring, such as 7-day Holter or an implantable loop recorder, could enhance the detection of recurrent ATa [20]. Unlike catheter ablation, little is known about the benefits of cavotricuspid isthmus (CTI) ablation in total thoracoscopic ablation (TTA) of atrial fibrillation (AF). In addition, patients in the CTI ablation group were followed up for a longer period than those in the non-CTI ablation group. In our study population, 3 patients (13.6%) had CTI-dependent AFL among the 22 patients with symptomatic recurrent ATa undergoing electrophysiological study or catheter ablation. This was indeed the reason for difficulty in lesion formation and achievement of bidirectional block in our case. Categorical data were compared between groups using the χ2 test, while the Fisher’s exact test was used when ≥20% of the contingency cells had expected values <5. However, it remains unclear whether prophylactic cavotricuspid isthmus (CTI) ablation at the time of PVI improves long-term freedom from AF. Of the 29 patients, 26 (90%) had an inducible arrhythmia before CTI ablation--AF in 16, typical atrial flutter (AFL) in seven and atypical AFL in three. For this reason, we believe that our results have clinical significance in establishing the lesion sets of hybrid ablation procedures [19]. Epub 2015 May 26. Journal of Interventional Cardiac Electrophysiology. CI: confidence interval; CTI: cavotricuspid isthmus; LAVI: left atrium volume index; PV: pulmonary vein. Seven clinical variables, CTI ablation and endocardial PV touch-up were included in the multivariable analysis. Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. USA.gov. However, it may be premature to adopt a routine CTI ablation after TTA based on our results. A deep sub-Eustachian pouch may cause difficulty with CTI ablation because of poor blood flow, resulting in rapid temperature and impedance rise, possible coagulum formation, and inadequate lesion formation, while concomitantly increasing the risk of perforation. The Cox regression analysis was performed to identify the predictors of recurrent ATa after TTA. 3). hence, favoring the perpetuation of a reentrant circuit. Diagnostic catheters were positioned in the high right atrium, annular right atrium across the CTI, coronary sinus, and right ventricle. DOI: https://doi.org/10.1016/j.hrcr.2019.09.004. It should be noted that a lateral ablation line will not be effective if the “heat sink” phenomenon is due to a prominent RCA, as the caliber of the vessel is in fact larger more laterally on the tricuspid annulus. Get the latest research from NIH: https://www.nih.gov/coronavirus. Therefore, we investigated the incidence of recurrent atrial tachyarrhythmia (ATa) according to additional CTI ablation after TTA in patients with persistent AF. Procedural and 6‐month outcomes of ablation for AFL were retrospectively compared between consecutive patients undergoing either AI‐guided ablation of CTI (n = 43; AI target of 500 for anterior 2/3 segments and 400 for posterior 1/3 segments) or contact force (CF)‐guided ablation (n = 42) at a single center. The technique required a bilateral approach with 3 holes: a 5-mm port introduced in the 4th intercostal space at the midaxillary line and 2 ports placed in the 3rd intercostal space at the anterior axillary line and at the 6th intercostal space at the midaxillary line, respectively. CTI was ablated in patients with long-standing AF (continuous AF lasting for ≥1 year) or those who had AFL episodes during the admission period. Hye Bin Gwag, Dong Seop Jeong, Jin Kyung Hwang, Seung-Jung Park, Kyoung-Min Park, June Soo Kim, Young Keun On, Additional cavotricuspid isthmus ablation may reduce recurrent atrial tachyarrhythmia after total thoracoscopic ablation for persistent atrial fibrillation, Interactive CardioVascular and Thoracic Surgery, Volume 28, Issue 2, February 2019, Pages 177–182, https://doi.org/10.1093/icvts/ivy236. The sub-Eustachian pouch (pouch of Keith) is a physiologic depression of the CTI just anterior to the Eustachian ridge and laterally to the Thebesian valve at the orifice of the coronary sinus. Ablation index (AI) has been evaluated as guidance quality marker for pulmonary vein isolation, but not for linear ablation of the cavotricuspid isthmus (CTI) for typical right atrial flutter (AFL). We conducted this study to verify the effect of CTI ablation on ATa recurrence after TTA of AF. 2020 Mar;57(2):233-240. doi: 10.1007/s10840-019-00560-9. Please check for further notifications by email. Learn more. Prophylactic pulmonary vein isolation during isthmus ablation for atrial flutter: Three-year outcomes of the PREVENT AF I study. We excluded patients (i) with a previous history of catheter-based radiofrequency ablation for AF (n = 29), (ii) who never achieved sinus rhythm after TTA (n = 7) or (iii) who were lost to follow-up within 3 months after TTA (n = 1). Thank you for submitting a comment on this article. Particularly in terms of ablation lesion sets, endocardial lines are less well described than epicardial lines. There was no difference in baseline characteristics between the CTI ablation and non-CTI ablation groups, except for a higher number of male patients in the CTI ablation group. Epub 2019 May 17. Ganglionated plexuses were subsequently ablated with bipolar radiofrequency energy under high-frequency pacing. Continuous variables are presented as median (25th–75th percentiles) or mean ± standard deviation based on the assumption of normality, whereas categorical variables are presented as number and percentage. A decision was made to ablate the CTI. Bidirectional block established at the end of the procedure. The following approaches can be employed to address this problem: CTI ablation with uptitration of power guided by impedance and temperature monitoring, as performed in our case, can counteract the “heat sink” effect. A meta-analysis. Ablation index (AI) has been evaluated as guidance quality marker for pulmonary vein isolation, but not for linear ablation of the cavotricuspid isthmus (CTI) for typical right atrial flutter (AFL). All rights reserved. Conclusion: Previous studies not only showed that new-onset AF develops in a significant proportion of patients with AFL but also advocated ablation of AF at the time of CTI ablation in patients with AFL [4, 5, 9]. CTI ablation was performed in patients who had long-standing AF or atrial flutter episodes during the admission period. After one year of follow-up, 23 patients (79%) had no recurrence of arrhythmia.

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