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Atypical flutter: effectiveness of a systematic strategy based on comprehensive high-density map analysis
Session:
Comunicações Orais - Sessão 15 - Fibrilhação Auricular e Flutter atípico
Speaker:
Joana Brito
Congress:
CPC 2023
Topic:
C. Arrhythmias and Device Therapy
Theme:
05. Atrial Fibrillation
Subtheme:
05.9 Atrial Fibrillation - Other
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Joana Brito; Beatriz Valente Silva; Pedro Alves da Silva; Beatriz Garcia; Catarina Oliveira; Patrícia Teixeira; 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:Calibri,sans-serif"><strong>Introduction:</strong>High-density mapping tools expanded the mechanism characterization of atypical flutters (AFl), but a systematic analysis of substrate and activation maps is critical for proper interpretation and targeted ablation strategy. </span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Purpose:</strong>Between 2016 and 2017, we developed a comprehensive stepwise workflow for AFl map interpretation in 25 patients (pts). This study evaluates its effectiveness in a validation cohort. </span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong><span style="color:black">Methods:</span></strong><span style="color:black">Prospective single-center study of pts with left-sided AFl referred for ablation from 2018 to 2022. Pts with prior AFl ablation procedures were excluded. Complete high-density map collection was performed using Carto, Ensite or Rhythmia, while displaying only voltage data. The comprehensive workflow was applied for activation map interpretation, starting by facing the mitral annulus and following the sequence of colors to systematically identify all potential circuits, their common-isthmuses and slow-conduction sites. Additional algorithms (Coherent, Ripple, SparkleMap or LumiPoint) were used subsequently, at operator description, for interpretation validation purposes. A mechanism-tailored ablation strategy was applied targeting AFl common-isthmuses. If AFl persisted after completion of 1<sup>st</sup> ablation set, remap was performed and the mechanism was characterized. Acute success was defined as conversion to sinus rhythm with the completion of the final ablation set. Entrainment maneuvers were only used to confirm the circuit interpretation if AFl persisted after completion of the planned ablation set.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Results: </strong>A total of 68 pts were included in the AFl validation cohort (male 61.8%;67±13 yearsold). Substrate maps revealed low-voltage areas (<0.3 mV) out of the PV in 88%. AFl mechanism was macro-reentrant in 90%, most often with dual-loop circuits (51%, N=35) and including a perimitral rotation (53%, N=36pts). The 1<sup>st</sup> set of mechanism-tailored ablation restored sinus rhythm in 47 pts (69%). The residual AFl (N=21) was found to be: (1) same AFl using an ablation line gap in 3 pts; (2) same AFl using a loop previously not recognized in 1 pt; (3) a completely different AFl using a distinctive circuit (N=12); or (4) a right-sided peri-tricuspid flutter in 5 pts. Completion of the ablation set resulted in sinus rhythm restoration in 19 of these 21 pts, resulting in an overall acute success rate of 97% (66/68). In the remaining 2 pts, response to entrainment maneuvers was compatible with conduction persistence through the ablation line, being unsuccess explained by ablation failure. </span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Conclusion:</strong>This comprehensive stepwise workflow for AFl high-density map allows a mechanism-tailored ablation strategy resulting in a very high acute success rate. Our study enforces that if AFl persists after the 1<sup>st</sup> ablation set and a remap is pursued, additional targeted ablation results in a final procedural success.</span></span></p>
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