Incidence, duration, pattern, and burden of de novo atrial arrhythmias detected by continuous ECG monitoring using an implantable loop recorder following ablation of the cavotricuspid isthmus

Q: What does this research mean for the field?

Following cavotricuspid isthmus ablation in patients with atrial flutter, de novo atrial arrhythmias occur in the vast majority of patients, but the overall arrhythmia burden is low and most episodes last less than 24 hours. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Dan L. Musat; N Milstein; Jacqueline Pimienta; Advay G. Bhatt; Mark W. Preminger; Tina Sichrovsky; Laura Flynn; Carissa Pistilli; Richard E. Shaw; Suneet Mittal

doi:10.1016/j.cvdhj.2020.10.003

October 28, 2020Cardiovascular Digital Health JournalOpen Access

Incidence, duration, pattern, and burden of de novo atrial arrhythmias detected by continuous ECG monitoring using an implantable loop recorder following ablation of the cavotricuspid isthmus

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Why the study?

Following cavotricuspid isthmus ablation, many patients with atrial flutter develop atrial fibrillation, but its incidence, duration, pattern, and burden remain undefined.

Structured PICO

P

Population

52 consecutive patients with CTI-dependent atrial flutter (AFL), no known history of atrial fibrillation (AF), and CHA2DS2-VASc ≥ 2, mean age 73 ± 9 years, 81% male.

I

Intervention

Continuous ECG monitoring using an implantable loop recorder (ILR) implanted before or within 90 days of cavotricuspid isthmus (CTI) ablation.

O

Outcome

Incidence, duration, pattern, and burden of atrial fibrillation or atrial flutter (AF/AFL)surrogate

Continuous ILR monitoring reveals that while de novo AF/AFL is highly incident (85%) after CTI ablation for AFL, the overall arrhythmia burden remains low and episodes are typically short.

Implication

High AF incidence after CTI ablation for AFL does not yet change practice; leaves open need for ILR-guided management trials.

Abstract

BackgroundFollowing cavotricuspid isthmus (CTI) ablation, many patients with atrial flutter (AFL) are diagnosed with atrial fibrillation (AF). The incidence, duration, pattern, and burden of AF remain undefined. These may have implications for the management of these patients.ObjectiveTo classify the incidence, duration, pattern, and burden of AF/AFL using an implantable loop recorder (ILR) after CTI ablation.MethodsWe enrolled consecutive patients with CTI-dependent AFL, no known history of AF, and CHA2DS2-VASc ≥ 2. An ILR was implanted before or within 90 days of ablation. The time to first AF/AFL, pattern, duration, and burden of longest AF/AFL were determined. Five distinct AF/AFL cohorts were identified: no AF/AFL and those with recurrences of isolated, clustered, frequent, or persistent AF/AFL.ResultsFifty-two patients (81% male; 73 ± 9 years; CHA2DS2-VASc 3.7 ± 1.2) were followed for 784 (interquartile range [IQR] 263, 1150) days. AF/AFL occurred in 44 (85%) patients at 64 (IQR 8, 189) days post-CTI ablation and was paroxysmal in 31 (70%) patients (burden 0.6% [IQR 0.1, 4.8]). AF/AFL was isolated (n = 5, 11%), clustered (n =7, 16%), frequent (n =19, 43%), and persistent (n =13, 30%). The longest AF episode was <24 hours in 27 (61%) patients.ConclusionFollowing CTI ablation in AFL patients, although AF/AFL occurs in most patients, the burden is low and episodes were <24 hours in the majority of patients. Additional studies are needed to determine whether long-term electrocardiographic monitoring can help guide management of patients undergoing CTI ablation. Following cavotricuspid isthmus (CTI) ablation, many patients with atrial flutter (AFL) are diagnosed with atrial fibrillation (AF). The incidence, duration, pattern, and burden of AF remain undefined. These may have implications for the management of these patients. To classify the incidence, duration, pattern, and burden of AF/AFL using an implantable loop recorder (ILR) after CTI ablation. We enrolled consecutive patients with CTI-dependent AFL, no known history of AF, and CHA2DS2-VASc ≥ 2. An ILR was implanted before or within 90 days of ablation. The time to first AF/AFL, pattern, duration, and burden of longest AF/AFL were determined. Five distinct AF/AFL cohorts were identified: no AF/AFL and those with recurrences of isolated, clustered, frequent, or persistent AF/AFL. Fifty-two patients (81% male; 73 ± 9 years; CHA2DS2-VASc 3.7 ± 1.2) were followed for 784 (interquartile range [IQR] 263, 1150) days. AF/AFL occurred in 44 (85%) patients at 64 (IQR 8, 189) days post-CTI ablation and was paroxysmal in 31 (70%) patients (burden 0.6% [IQR 0.1, 4.8]). AF/AFL was isolated (n = 5, 11%), clustered (n =7, 16%), frequent (n =19, 43%), and persistent (n =13, 30%). The longest AF episode was <24 hours in 27 (61%) patients. Following CTI ablation in AFL patients, although AF/AFL occurs in most patients, the burden is low and episodes were <24 hours in the majority of patients. Additional studies are needed to determine whether long-term electrocardiographic monitoring can help guide management of patients undergoing CTI ablation.