Published Online
on June 23, 2009

A more recent version of this article appeared on August 1, 2009

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Original Article

Long-Term Outcomes After Catheter Ablation of Cavo-Tricuspid Isthmus Dependent Atrial Flutter: A Meta-Analysis

Francisco J. Pérez; Christine M. Schubert; Babar Parvez; Vishesh Pathak; Kenneth A. Ellenbogen and Mark A. Wood¹

Virginia Commonwealth University Medical Center, Richmond, VA

¹ E-mail: mwoodmd{at}pol.net

Background—Despite the success of catheter ablation of cavotricuspid isthmus dependent atrial flutter (AFL), important post ablation outcomes are ill-defined. The purpose of our study was to analyze long-term outcomes after catheter ablation of CTI dependent AFL.

Methods and Results—A meta-analysis was performed of articles reporting clinical outcomes after catheter ablation of AFL published between January 1988 and July 2007. The analysis included 158 studies comprising 10,719 patients (79% male, 59.8±0.5 years old, 46% left atrial enlargement, 46% heart disease, 42% with history of atrial fibrillation, 14.3 ± 0.4 months follow up). The overall acute success rate adjusted for reporting bias was 91.1% (95% CI 89.5- 92.4 %); 92.7% (CI 90.0 – 94.8%) for 8 mm to 10 mm tip/ or irrigated RF catheters and 87.9% (CI 84.2 - 90.9%) for 4 to 6 mm tip catheters (p > 0.05). Atrial flutter recurrence rates were significantly reduced by use of 8 to 10 mm tip or irrigated RF catheters (6.7% vs 13.8%, p < 0.05) and by use of bidirectional cavotricuspid isthmus block as a procedural endpoint (9.3% vs 23.6%, p < 0.05). The AFL recurrence rate did not increase over time. The overall occurrence rate of atrial fibrillation after AFL ablation was 33.6% (CI 29.7 - 37.3%) but was 52.7% (CI 47.8 – 57.6%) in patients with a history of atrial fibrillation prior to ablation, and 23.1% (CI 17.5 – 29.9%) in those without atrial fibrillation prior to ablation (p < 0.05). The incidence of atrial fibrillation increased over time in both groups, however, 5 years after ablation, the incidence of AF was similar in those with and without AF prior to ablation. The acute complication rate was 2.6% (CI 2-3%). The mortality rate during follow up was 3.3% (CI 2.4 – 4.5%). Antiarrhythmic drug use post ablation was 31.6% (CI 25.6 – 37.8%). The long term use of coumadin was 65.9%, (CI 43.8 – 82.8%). Quality of life data was very limited.

Conclusions—AFL ablation is safe and effective. Ablation technology and procedural endpoints have greater influences on AFL recurrences than on acute ablation success rates. Atrial fibrillation is common after AFL ablation. Almost one third of patients take antiarrhythmic drugs after AFL ablation. Atrial fibrillation prior to AFL ablation may indicate a more advanced state of electrical disease.

Key Words: ablation • atrial flutter • atrial fibrillation • catheter ablation • meta-analysis