High Energy Radiofrequency Catheter Ablation for Common Atrial Flutter Targeting the Isthmus between the Inferior Vena Cava and Tricuspid Valve Annulus Using a Super Long Tip Electrode

There have been controversies concerning the optimal target sites and approaches in radiofrequency catheter ablation of common atrial flutter. We attempted high energy radiofrequency catheter ablation targeting the isthmus between the inferior vena cava and tricuspid valve annulus (IVC-TV isthmus) with a super long (8 mm) tip electrode, and compared the efficacy of this anatomical approach with the electrophysiological approach targeting the posteroseptal right atrium posterior to the coronary sinus using a standard 4-mm tip electrode. Atrial flutter was successfully ablated in 12 of 12 patients (100%) without recurrence with the anatomical approach, while, in 7 of 9 patients (64%) with 2 recurrences with the electrophysiological approach. In comparison of ablation data between the anatomical and electrophysiological approaches, there were significant differences in the mean number of application pulses (anatomical vs electrophysiological: 2.3 +/- 0.8 vs 9.9 +/- 6.4, P < 0.01), applied wattage (39 +/- 12 W vs 24 +/- 6 W, P < 0.01), applied energy per application (1,986 +/- 426 J vs 659 +/- 323 J, P < 0.01), fluoroscopic time (26 +/- 11 min vs 74 +/- 30 minutes, P < 0.01), and procedure time (59 +/- 8 min vs 181 +/- 53 min, P < 0.01). In conclusion, the anatomical approach is superior to the electrophysiological one with respect to procedure and radiation time, and linear ablation at the IVC-TV isthmus with an 8-mm tip electrode and high energy application is highly effective and safe.