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Outcomes of Atypical Flutter Ablation Guided Exclusively by Systematic Analysis of High-Resolution Maps (No Entrainment Maneuvers)
Session:
SESSÃO DE POSTERS 53 - FIBRILHAÇÃO AURICULAR E ARRITMIAS AURICULARES COMPLEXAS
Speaker:
Francisco Salvaterra
Congress:
CPC 2025
Topic:
C. Arrhythmias and Device Therapy
Theme:
06. Supraventricular Tachycardia (non-AF)
Subtheme:
06.4 Supraventricular Tachycardia (non-AF) - Treatment
Session Type:
Cartazes
FP Number:
---
Authors:
Francisco Salvaterra; Joana Brito; Ana Abrantes; Daniel Inácio Cazeiro; Miguel Azaredo Raposo; Joana Quaresma; Afonso Nunes Ferreira; Gustavo Lima da Silva; Luís Carpinteiro; Nuno Cortez-Dias; Fausto J. Pinto; João de Sousa
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><strong>Introduction:</strong> Advancements in mapping systems have enhanced our understanding of atypical flutter (AFl) mechanisms. Systematic analysis of substrate and activation maps is crucial for arrhythmia interpretation and defining targeted ablation strategies.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><strong>Purpose:</strong> To evaluate the outcomes of AFl ablation exclusively guided by systematic analysis of high-resolution maps.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><strong>Methods:</strong> This is a single-center retrospective study of left-sided AFl patients (pts) who underwent ablation from 2015 to June 2024. High-resolution map interpretation was conducted following a systematic predefined workflow aimed at identifying the AFl mechanism and planning ablation lines targeting the critical isthmus. No entrainment maneuvers were performed. If AFl persisted after the first ablation set, a remap was performed. Acute success was defined as conversion to sinus rhythm with the planned ablation set. The procedure endpoint was the demonstration of conduction block over ablation lines. Outcomes were evaluated by survival free from any sustained atrial arrhythmia.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><strong>Results:</strong> A total of 128 pts were treated, 58% male, with a mean age of 68±11 years. About 52% had undergone prior pulmonary vein isolation, with an additional left atrial linear ablation in 16% (n=20). A macroreentrant circuit was observed in 84% of pts, using 2- or 3-loops in 46.8%, with single-loop flutters representing 35.1% (Figure 1). The perimitral loop was the most frequent reentrant circuit (n=51, 56%). The first set of mechanism-tailored ablation restored sinus rhythm in 81 pts (63%). If AFl persisted, the mechanism was most often a completely distinctive left-sided circuit (n=27) or a right-sided peri-tricuspid (n=8). Completion of the ablation set restored sinus rhythm in 37 of these 47 pts, resulting in an overall acute success rate of 92% (118/128). Pts were followed over a median of 4.2 [2.7-5.6] years. After a single procedure, the 1-year success rate was 76%, decreasing to 51% at 3 years (Figure 2). A total of 22 pts underwent a redo procedure, consisting of typical AFl ablation in 3, PVI isolation in 1, focal AT in 1, and atypical AFl redo in 17 pts. Including redos, arrhythmia-free survival increased to 81% at 1 year and 58% at 3 years. In 10 pts (7.8%), AV nodal ablation was performed due to persistent arrhythmia.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><strong>Conclusion:</strong> The AFl mechanism identified through a systematic mapping approach was dual-loop reentry more commonly than presumed by studies based on entrainment maneuvers. Ablation targeting the shared isthmus resulted in high acute success with acceptable long-term outcomes.</span></span></p>
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