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Catheter ablation of atypical atrial flutter: a novel 3D anatomic mapping approach to quickly localize and terminate atypical atrial flutter

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Abstract

Purpose

This study aims to describe a novel method of High Density Activation Sequence Mapping combined with Voltage Gradient Mapping Overlay (HD-VGM) to quickly localize and terminate atypical atrial flutter.

Methods

Twenty-one patients presenting with 26 different atypical atrial flutter circuits after a previous catheter or surgical AF ablation were studied. HD-VGM was performed with a commercially available impedance-based mapping system to locate and successfully ablate the critical isthmus of each tachycardia circuit. The results were compared to 21 consecutive historical control patients who had undergone an atypical flutter ablation without HD-VGM.

Results

Twenty-six different atypical flutter circuits were evaluated. An average 3D anatomic mapping time of 12.39 ± 4.71 min was needed to collect 2996 ± 690 total points and 1016 ± 172 used mapping points. A mean of 195 ± 75 s of radiofrequency (RF) energy was needed to terminate the arrhythmias. The mean procedure time was 135 ± 46 min. With a mean follow-up 16 ± 9 months, 90% are in normal rhythm. In comparison to the control cohort, the study cohort had a shorter procedure time (135 ± 46 vs. 210 ± 41 min, p = 0.0009), fluoroscopy time (8.5 ± 3.7 vs. 17.7 ± 7.7 min, p = 0.0021), and success in termination of the arrhythmia during the procedure (100 vs. 68.2%, p = 0.0230).

Conclusions

Ablation of atypical atrial flutter is challenging and time consuming. This case series shows that HD-VGM mapping can quickly localize and terminate an atypical flutter circuit.

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Abbreviations

AF:

Atrial fibrillation

PAF:

Paroxysmal atrial fibrillation

pAF:

Persistent atrial fibrillation

HD-VGM:

High Density Activation Sequence Mapping with Voltage Gradient Mapping Overlay

aAFL:

Atypical atrial flutter

LA:

Left atrium

RA:

Right atrium

CS:

Coronary Sinus

LAT:

Local activation timing

RAI:

Roving activation interval

LVID:

Low-V ID

ACT:

Activated clotting time

ICE:

Intracardiac echo

LSI:

Lesion size index

FTI:

Force Time Integral

RF:

Radiofrequency

CAFÉ:

Complex atrial fractionated electrograms

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Acknowledgments

The authors thank Ms. Kim Oaks for the editorial assistance and Ms. Manya Harsch for the statistical assistance.

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Authors and Affiliations

  1. Cardiac Electrophysiology, South Denver Cardiology Associates, Littleton, CO, 80120, USA

    Sri Sundaram, William Choe & J. Ryan Jordan

  2. St. Jude Medical, One St. Jude Medical Drive, St. Paul, MN, 55117, USA

    Nate Mullins & Charles Boorman

  3. Cardiac Electrophysiologist, Cardiac EP Consultants, 900 Technology Way, Libertyville, IL, 60048, USA

    Eric J. Kessler

  4. Colorado Springs Cardiology, 2222 N Nevada Ave, Suite 4007, Colorado Springs, CO, 80907, USA

    Sunil Nath

Authors
  1. Sri Sundaram
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  2. William Choe
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  3. J. Ryan Jordan
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  4. Nate Mullins
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  5. Charles Boorman
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  6. Eric J. Kessler
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  7. Sunil Nath
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Corresponding author

Correspondence to Sri Sundaram.

Ethics declarations

This study was approved by our local institutional review board.

Conflict of interest

Drs. Sundaram and Choe are on the speaker’s bureau for St. Jude Medical. In addition, Drs. Sundaram and Choe have received a research grant from St. Jude Medical, Asia Division, to study the genetic basis of Brugada Syndrome in Cambodia. This conflict is not relevant to the article. N. Mullins and C. Boorman receive salary support from St. Jude Medical.

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Sundaram, S., Choe, W., Ryan Jordan, J. et al. Catheter ablation of atypical atrial flutter: a novel 3D anatomic mapping approach to quickly localize and terminate atypical atrial flutter. J Interv Card Electrophysiol 49, 307–318 (2017). https://doi.org/10.1007/s10840-017-0269-z

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  • DOI: https://doi.org/10.1007/s10840-017-0269-z

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