8.8 Ablation of left atrial flutter after surgical treatment of atrial fibrillation

AbstractImpaired left atrial appendage ejection fraction (LAA-EF) and peak LAA flow velocity (LAA-FV) are associated with high thromboembolic risks in patients with atrial fibrillation (AF). Herein, we examined LAA function among patients with atrial flutter (AFL) stratified by the CHA2DS2-VASc score using transesophageal echocardiography (TEE). Of 231 consecutive patients with typical AFL, 84 who fulfilled the inclusion criteria were enrolled. Among them, 57 had ongoing AFL and were divided into the isolated AFL (n = 38) and AFL with paroxysmal AF (PAF) (n = 19) groups, depending on whether they had sporadic AF before TEE. The remaining 27 patients with spontaneous sinus rhythm during TEE were designated as controls. Both the LAA-FV (31.9 cm/s vs. 51.5 cm/s, P = 0.004) and LAA-EF (28.4% vs. 36.5%, P = 0.024) measured during AFL were significantly lower in the AFL + PAF group than in the isolated AFL group. Significant inverse correlations between the CHA2DS2-VASc score and LAA-EF were identified in the AFL (P = 0.008) and AFL + PAF (P = 0.032) groups. We observed progressive LAA dysfunction in patients with AFL + PAF compared with that in patients with isolated AFL, and the LAA-EF was inversely correlated with the CHA2DS2-VASc score in these patients. Our findings may have implications on the application of thromboprophylactic therapy in patients with AFL.

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A Stunning Left Atrial Appendage Thrombus

Cardiology ◽

10.1159/000444166 ◽

2016 ◽

Vol 134 (4) ◽

pp. 394-397

Author(s):

Sajid Ali ◽

Justin Ugwu ◽

Yousuf Kanjwal

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Atrial Flutter ◽

Pulmonary Vein ◽

Left Atrial ◽

Left Atrial Appendage ◽

Thrombus Formation ◽

Atrial Appendage ◽

Transesophageal Echocardiogram ◽

Left Atrial Appendage Thrombus

Background: Left atrial appendage thrombus formation is a known major complication of atrial fibrillation and atrial flutter which increases the risk of embolism and stroke. This risk of thrombosis is greatly increased with a lack of anticoagulation. After conversion to a normal sinus rhythm in these arrhythmias, the risk of thrombus formation in the left atrium persists through a phenomenon termed atrial myocardial stunning. Case: We present the case of a patient who previously underwent successful pulmonary vein isolation and was found to be in typical isthmus-dependent atrial flutter with a questionable recurrence of atrial fibrillation. The decision was made to return for atrial flutter ablation and for evaluation of prior pulmonary vein isolation. Initially, a transesophageal echocardiogram showed a normal ejection fraction, biatrial enlargement and no left atrial appendage thrombus. Ablation of the cavotricuspid isthmus was successfully accomplished with documented bidirectional block. A transesophageal echocardiogram probe was still in place prior to planned transseptal puncture for the evaluation of pulmonary veins. A large thrombus was now observed filling the left atrial appendage. Conclusion and Objective: Atrial stunning is a transient atrial contractile dysfunction that occurs whether sinus rhythm is restored spontaneously, electrically, pharmacologically or by ablation. We know after conversion that there is higher propensity to increased spontaneous echogenic contrast and decreased velocities; however, we do not have documented knowledge of exactly how soon after the conversion to a sinus rhythm a thrombus may be seen. We demonstrate a case of acute left atrial appendage thrombus formation immediately following the successful ablation of isthmus-dependent atrial flutter. Our report validates the belief that strategies of not interrupting anticoagulation prior to the conversion of these arrhythmias should be implemented.

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Image fusion shows the role of incomplete ablation lines in creating a substrate for left atrial flutter occurring after atrial fibrillation ablation

Heart Rhythm ◽

10.1016/j.hrthm.2007.09.021 ◽

2008 ◽

Vol 5 (1) ◽

pp. 163-164 ◽

Cited By ~ 2

Author(s):

Maurizio Del Greco ◽

Alessandro Cristoforetti ◽

Massimiliano Marini ◽

Flavia Ravelli

Keyword(s):

Atrial Fibrillation ◽

Image Fusion ◽

Atrial Flutter ◽

Left Atrial ◽

Atrial Fibrillation Ablation

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Left Atrial Flutter After Radiofrequency Catheter Ablation of Focal Atrial Fibrillation

Journal of Cardiovascular Electrophysiology ◽

10.1046/j.1540-8167.2003.02418.x ◽

2003 ◽

Vol 14 (4) ◽

pp. 417-421 ◽

Cited By ~ 55

Author(s):

JULIÁN VILLACASTÍN ◽

NICASIO PÉREZ‐CASTELLANO ◽

JAVIER MORENO ◽

ROSA GONZÁLEZ

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Atrial Flutter ◽

Left Atrial ◽

Radiofrequency Catheter Ablation

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Catheter Ablation of Atypical Atrial Flutter and Atrial Tachycardia Within the Coronary Sinus After Left Atrial Ablation for Atrial Fibrillation

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2005.03.053 ◽

2005 ◽

Vol 46 (1) ◽

pp. 83-91 ◽

Cited By ~ 82

Author(s):

Aman Chugh ◽

Hakan Oral ◽

Eric Good ◽

Jihn Han ◽

Kamala Tamirisa ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Atrial Flutter ◽

Coronary Sinus ◽

Left Atrial ◽

Atrial Tachycardia ◽

Atrial Ablation

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Predictors of Failure Cardioversion for Recurrent Atrial Fibrillation Following Mitral Valve Surgery With Ablation

The Heart Surgery Forum ◽

10.1532/hsf.2997 ◽

2020 ◽

Vol 23 (3) ◽

pp. E300-E304

Author(s):

Hailong Cao ◽

Xin Chen ◽

Xiyu Zhu ◽

Yining Yang ◽

Qing Zhou ◽

...

Keyword(s):

Atrial Fibrillation ◽

Radiofrequency Ablation ◽

Mitral Valve ◽

Atrial Flutter ◽

Left Atrial ◽

Mitral Valve Surgery ◽

Valve Surgery ◽

Loading Dose ◽

Left Atrial Diameter ◽

Recurrent Atrial Fibrillation

Background: Electrical cardioversion (ECV) often is required for terminating recurrent atrial fibrillation (AF) after surgical radiofrequency ablation in patients undergoing mitral valve surgery. However, ECV is unsuccessful in some cases. In this study, we aimed to identify possible predictors of failed ECV for recurrent atrial fibrillation following mitral valve surgery with concomitant radiofrequency ablation. Methods: We enrolled 1,136 persistent AF patients with history of mitral valve surgery and concomitant radiofrequency ablation. Three-hundred-nineteen patients experienced recurrence of persistent AF and received ECV therapy. Comparison was made between patients with failed ECV (Failure group, N = 68) and successful ECV (Success group, N = 251). Results: In multivariate regression analysis, age, pre-ECV loading-dose amiodarone, left atrial diameter, atrial flutter and time from surgery to ECV were independent predictors for outcomes of ECV. According to receiver operating characteristic curve analysis, the best threshold values of age, left atrial diameter and time from surgery to ECV for predicting failed ECV were 55.5 years, 64.5 mm, and 90.5 days, respectively. Conclusion: Older age, larger left atrium and longer time from surgery to ECV are independent predictors for failed ECV in this group. Compared with AF, atrial flutter is easier to be successfully terminated by ECV. Pre-ECV loading-dose amiodarone is helpful for successful ECV. These findings have important implications for identifying the kinds of patients to receive effective ECV.

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Key Role of Left Atrial Appendage during Redo Ablation in a Case of Long-Standing Persistent Atrial Fibrillation

Case Reports in Cardiology ◽

10.1155/2020/9691584 ◽

2020 ◽

Vol 2020 ◽

pp. 1-4

Author(s):

Shaohui Wu ◽

Guangchen Zou ◽

Xu Liu ◽

Weifeng Jiang ◽

Mu Qin ◽

...

Keyword(s):

Atrial Fibrillation ◽

Atrial Flutter ◽

Left Atrial ◽

Left Atrial Appendage ◽

Persistent Atrial Fibrillation ◽

The Other ◽

Atrial Appendage ◽

Electrical Isolation ◽

Rare Phenomenon

Extrapulmonary vein focal sources have been recognized as the source of atrial fibrillation in some cases, and empiric electric isolation of the left atrial appendage has been proposed for long-standing persistent atrial fibrillation by some. Here, we present a case of redo ablation of long-standing persistent atrial fibrillation in which the left atrial appendage played a key role in maintaining AF during ablation, and atrial fibrillation was terminated by electrical isolation of the LAA. During the ablation, a rare phenomenon of half of the atria in atrial fibrillation while the other half of the atria in atrial flutter was seen.

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P426Routine use of transoesophageal echocardiography in patients with atrial fibrillation or atrial flutter undergoing cardioversion

EP Europace ◽

10.1093/europace/euaa162.110 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

K Etsadashvili ◽

N Kuridze ◽

T Kavtiashvili ◽

T S Chaligava ◽

V Chumburidze

Keyword(s):

Atrial Fibrillation ◽

Atrial Flutter ◽

Left Atrial ◽

Anticoagulation Therapy ◽

Transoesophageal Echocardiography ◽

Right Atrial ◽

Cardiac Thrombus ◽

Group 2 ◽

Anticoagulated Patients ◽

Group 1

Abstract Background. According to the recent guidelines, effective anticoagulation is recommended for a minimum of 3 weeks before the cardioversion of Atrial Fibrillation/Atrial Flutter. Transoesophageal echocardiography (TOE) could be considered, but is not mandatory to exclude/confirm the cardiac thrombus before the cardioversion in adequately anticoagulated patients. Aim of the study was to reveal the incidence of thrombus or spontaneous echo contrasting (SEC) by TOE before cardioversion, despite effective anticoagulation. Material and methods. Patients, where TOE was performed to evaluate the evidence of thrombus/SEC before the cardioversion of AF/Atrial flutter at our clinic in period of 2016-2018, were studied. Incidence of intracardiac thrombus and its relation to patients’ gender, age, hypertension, diabetes, atrial diameter, LVEF, duration of Atrial Fibrillation/Atrial flutter, as well as to anticoagulation regimen were evaluated. Results. All patients received recommended anticoagulation therapy, DOACs or VKAs, for a minimum of 3 weeks before the TOE. Finally 180 patients were divided in two groups: group 1 (121 patients) without evidence of thrombus and group 2 (59 patients) where TOE revealed the thrombus. Thrombus was found in 37 (20.5%) patients, and SEC was found in 22 (12.2%) patients. There were no difference between the two groups with respect to: gender (85 male (70%) in group 1 vs. 38 male (64%) in group 2, p = NS), age (62.8 ± 8.73 vs. 63.0 ± 9.04, p = NS), hypertension (78 (64.4%) vs. 44 (74.6%), p = NS), diabetes (17 (14%) vs. 7 (12%), p = NS), CHAD2DS2-VASc score (2.2 ± 1.8 vs. 2.4 ± 4.0, p = NS), LVEF (48.1 ± 7.1% vs. 46.4 ± 7.3%, p = NS), duration of arrhythmia (7.7 ± 11.6 months vs. 9.7 ± 14.0 months, p = NS), type on anticoagulation (DOACs 59 (48.3%) vs. 30 (50.8%), p = NS, VKA (Warfarin) 54 (44.6%) vs. 29 (49.1%), p = NS)) respectively. Only difference in atrial diameter was found statistically significant between the two groups: left atrial diameter (42.6 ± 3.3mm vs. 45.3 ± 3.6mm, p < 0.001) and right atrial diameter (39.4 ± 3.3mm vs. 40.8 ± 2.3mm, p = 0.001) respectively. Conclusion. Thrombus/SEC could persist despite the effective anticoagulation therapy for ≥3 weeks. Therefore all patients should perform TOE before the cardioversion to avoid the incidence of stroke.

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