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Evaluation of an Individualized Strategy of Cavotricuspid Isthmus Ablation as an Adjunct to Atrial Fibrillation Ablation


  • Dipen Shah has accepted speaking assignments and is or has been a consultant for Biosense Webster, Bard Electrophysiology, and Endosense.

  • The Cardiology service received grant support from Medtronic, Biosense Webster, and Guidant.

  • Manuscript received 2 March 2007; Revised manuscript received 27 April 2007; Accepted for publication 18 May 2007.

Address for correspondence: Dipen C. Shah, M.D., Centre de Cardiologie, Hopital Cantonal de Geneve, Rue Micheli-du-Crest, 24, 1211 Geneve 14, Switzerland. Fax: +41-22-372-7229; E-mail:


Objectives: To evaluate supplementary cavotricuspid isthmus (CTI) ablation as an adjunct to atrial fibrillation (AF) ablation in selected patients.

Background: It is unclear whether routine CTI ablation is beneficial in all patients undergoing AF ablation.

Methods and Results: In patients undergoing AF ablation, additional CTI block was created only for those with typical atrial flutter (Afl) before or during the ablation. Out of 188 consecutive patients (108 male, 56 ± 9 years), 75 underwent CTI ablation (Group CTI+) and left atrial (LA) ablation (circular mapping-guided extensive pulmonary vein isolation in all and linear LA ablation when required), while 113 underwent LA ablation alone (Group CTI−). Group CTI+ patients had smaller LA and less frequently persistent/permanent AF and linear LA ablation. Over a follow-up of 30 ± 10 months, complications (4% vs 5%, P = NS), typical Afl occurrence (1.3% and 2.6%, P = NS) and AF recurrence (25% and 28%, P = NS) were similar. Atypical Afl was more common in Group CTI− (4 vs 14%, P = 0.026). Eighty-two percent and 79% of patients in Groups CTI+ and CTI−, respectively, remained arrhythmia free in stable sinus rhythm without antiarrhythmic drug treatment (P = NS).

Conclusions: Avoiding supplementary CTI ablation in AF ablation patients without evidence of typical flutter does not result in a higher incidence of typical Afl. Despite more persistent/permanent AF and larger LA in patients without evidence of typical flutter, a strategy of selective supplementary ablation resulted in similar and low AF recurrence rates in the group without CTI ablation compared with the group with CTI ablation.