Key result
A right atrial pouch was significantly more frequent in patients with prolonged cavotricuspid isthmus ablation time ≥11 min compared to those with <11 min (75.0% vs 26.7%, P=0.012).
Why the study?
Does pre-procedural 3D-TEE imaging identify anatomic structures associated with prolonged ablation time in patients undergoing RFA for typical atrial flutter?
Observational (n=31)
Single-blind
Does pre-procedural 3D-TEE imaging identify anatomic structures associated with prolonged ablation time in patients undergoing RFA for typical atrial flutter?
Absolute Event Rate: 75% vs 26.7%
p-value: p=0.012
Pre-procedural 3D-TEE can identify a deep right atrial pouch, which is associated with significantly prolonged CTI ablation time during typical atrial flutter ablation.
Right atrial pouch on 3D-TEE was associated with prolonged CTI ablation; hypothesis-generating for pre-procedural imaging to predict procedural difficulty.
Aims: Radiofrequency ablation (RFA) is the treatment of choice of cavotricuspid isthmus (CTI)-dependent atrial flutter. Procedural time is highly variable due to anatomical structures. This study aimed to characterize CTI anatomy by transesophageal 3D echocardiography imaging (3D-TEE) to identify anatomic structures related to longer ablation time. Methods and results: Thirty-one consecutive patients (mean age 67.3 ± 11.5 years, 22 males) underwent CTI-ablation procedure. Before ablation, TEE was performed and 3D-TEE images were acquired to evaluate CTI anatomy qualitatively as well as perform measures of CTI morphological features. The electrophysiologist performing RFA was blinded to 3D-TEE data. Bidirectional block of CTI was achieved in all patients without procedural complications after a median ablation time of 11 (IQR 7-14) min. Patients with RFA time ≥11 min (Group 2) presented lower left ventricular ejection fraction (51.1 ± 17.0 vs. 59.5 ± 6.6%, P < 0.010), a larger left atrium (46.2 ± 8.4 vs. 39.9 ± 9.4 mm, P < 0.058), and, more frequently, a right atrial pouch (12/16 patients vs. 4/15, P = 0.012) compared with patients with RFA time < 11 min (Group 1); CTI pouch was significantly deeper in Group 2 compared with Group 1: telediastolic (TD) pouch depth was 10.4 ± 4.5 vs. 6.3 ± 1.5 mm (P = 0.003) and telesystolic (TS) depth 12.8 ± 4.4 vs. 7.0 ± 1.4 mm (P < 0.001), respectively. TD isthmus length, prominent pectinate muscle, and presence of an Eustachian ridge (ER) did not differ between the two groups. Conclusion: Routine pre-procedural 3D-TEE imaging is extremely helpful in qualitative and quantitative evaluation of CTI anatomy in patients undergoing RFA for symptomatic typical atrial flutter. Detection of a deep right atrial pouch was found to be associated with significantly prolonged CTI ablation time to achieve bidirectional block.
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Regoli et al. (2017) conducted an observational in Typical atrial flutter (n=31). Prolonged radiofrequency ablation time (≥11 min) vs. Radiofrequency ablation time <11 min was evaluated on Presence of a right atrial pouch (p=0.012). A right atrial pouch was significantly more frequent in patients with prolonged cavotricuspid isthmus ablation time ≥11 min compared to those with <11 min (75.0% vs 26.7%, P=0.012).
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