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Department of Cardiology, Westmead Hospital and University of Sydney, Westmead NSW 2145, Australia
(Email: stuartpt{at}yahoo.com).
Typical atrial flutter is due to a macro-re-entrant circuit in the right atrium. The tricuspid annulus and the crista terminalis form the anterior and posterior boundaries for this circuit. Mechanical interruption of typical atrial flutter is usually achieved by linear ablation of tissue or incisions joining the tricuspid annulus to the inferior vena cava or Eustachian ridge. The relationship between atrial fibrillation and atrial flutter is an important one. Two very recent studies have documented a high incidence of atrial fibrillation after isolated percutaneous catheter-based cavo-tricuspid isthmus ablation for typical atrial flutter. However, data about the incidence of cavo-tricuspid isthmus-dependent (typical) atrial flutter after left atrial procedures for cure of atrial fibrillation is limited. In many studies, mechanisms of atrial flutter after surgery for atrial fibrillation are not explored. Where the mechanism of atrial flutter has been studied by a catheter-based electrophysiological study, a break in a line of ablation (usually in the left atrium) remains the most common mechanism. Cavo-tricuspid isthmus-dependent typical atrial flutter has been detected in a significant minority of cases.
Onorati and colleagues [1] use an historical control group to compare a left atrial maze procedure with an identical procedure including a continuous line of ablation between the inferior vena cava and tricuspid annulus. Studies designed to determine the differences in efficacy and safety associated with small variations in technique are relatively rare in this field; therefore, the authors are to be commended. A significant finding of this study was the difference in incidence of postoperative atrial flutter. However, the results need to be interpreted with caution for the following reasons: (1) the number of patients described in the study was small, (2) the historical rather than randomized control group introduces several potential biases including the effect of possible temporal improvements in technique, (3) the use of an historical control meant that follow-up was shorter in the group receiving a cavo-tricuspid isthmus connection, and (4) the study conclusions would be more compelling if the cavo-tricuspid isthmus dependence of the clinical postoperative atrial flutters was confirmed by electrophysiological studies.
The question addressed by the article of Onorati and colleagues [1] is an important one and their study provides additional data on the usefulness or otherwise of right atrial lesions in curative procedures for atrial fibrillation. However, the study limitations are important and prevent unreserved acceptance of the authors’ conclusions. A randomized study is required to further define the role of cavo-tricuspid isthmus ablation in this setting.
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