Partial cavotricuspid isthmus block before ablation in patients with typical atrial flutter

The purpose of this study was to prospectively evaluate preexisting partial isthmus block in the context of an electrophysiologically directed linear ablation strategy for typical atrial flutter (AF).

Double potentials (DPs) separated by an isoelectric interval have been recognized as markers of local block. However, the presence and significance of DPs in the cavotricuspid isthmus during AF before ablation have not been evaluated.

Thirty consecutive patients with AF (counterclockwise: 24, clockwise: 6) were studied during AF. Sequential withdrawal mapping was performed in the cavotricuspid isthmus from the tricuspid valve (TV) to the inferior vena cava (IVC) edge with electrograms coinciding with the center of the surface electrocardiographic plateau during counterclockwise AF or with the initial downslope of the positive flutter wave during clockwise AF. Atrial electrograms along this line were categorized as double, single or fractionated potentials (SPs or FPs). After demarcation of the zone of contiguous DPs, radiofrequency (RF) catheter ablation was performed during AF only at sites with SPs or FPs (other than DPs) on the mapped line. If isthmus conduction still persisted after AF termination, additional RF applications were delivered using the same electrophysiologic strategy of avoiding DPs with an isoelectric interval during low lateral right atrial pacing for filling in the gap of residual conduction.

Before ablation, no DPs were recorded in the isthmus in 19 patients (63%); DPs were recorded only at the IVC edge in five patients, and only at the TV edge in one patient. A contiguous line of DPs extending through more than half the isthmus to the IVC edge was documented in five patients (17%: group DP). In group DP, AF was terminated with 1.4+/-0.5 applications (vs. 5.8+/-3.5 in the remaining patients: p < 0.01). Complete isthmus block was achieved with a total of 3.4+/-0.5 applications (vs. 12+/-6 in the remaining patients: p < 0.01).

Seventeen percent of patients undergoing ablation of AF have preexisting partial isthmus block indicated by a large contiguous zone of DPs separated by an isoelectric interval. Electrophysiologically directed linear ablation avoiding confluent DPs can prevent unnecessary applications for effective cure of AF.