New-onset atrial fibrillation after cavotricuspid isthmus ablation: identification of advanced interatrial block is key

AIMS: A significant proportion of patients develop atrial fibrillation (AF) following cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFl). The objective of this study was to assess whether the presence of advanced interatrial block (aIAB) was associated with an elevated risk of AF after CTI ablation in patients with typical AFl and no prior history of AF. METHODS AND RESULTS: This study included patients with typical AFl and no prior history of AF that were referred for CTI ablation. Patients were excluded when they had received repeat ablations or did not demonstrate a bidirectional block. In all patients, a post-ablation electrocardiogram (ECG) in sinus rhythm was evaluated for the presence of aIAB, defined as a P-wave duration ≥120 ms and biphasic morphology in the inferior leads. New-onset AF was identified from 12-lead ECGs, Holter monitoring, and device interrogations. The cohort comprised 187 patients (age 67 ± 10.7 years; ejection fraction 55.8 ± 11.2%). Advanced interatrial block was detected in 18.2% of patients, and left atrium was larger in patients with aIAB compared with those without aIAB (46.2 ± 5.9 vs. 43.1 ± 6.0 mm; P = 0.01). Over a median follow-up of 24.2 months, 67 patients (35.8%) developed new-onset AF. The incidence of new-onset AF was greater in patients with aIAB compared with those without aIAB (64.7 vs. 29.4%; P < 0.001). After a comprehensive multivariate analysis, aIAB emerged as the strongest predictor of new-onset AF [odds ratio (OR) 4.2, 95% confidence interval (CI): 1.9-9.3; P < 0.001]. CONCLUSION: Advanced interatrial block is a key predictor for high risk of new-onset AF after a successful CTI ablation in patients with typical AFl.