EXPERIENCE WITH RADIOFREQUENCY ABLATION OF ISTHMUS-DEPENDENT ATRIAL FLUTTER SHORTLY AFTER OPEN-HEART SURGERY

To study effectiveness of radiofrequency ablation (RFA) of isthmus-dependent atrial flutter in the early post-operation period after open-heart surgery conducted in January 2012 through November 2013, 185 patients aged 58.4±8.4 years including 142 men (76.8%) were assessed. Group I included 14 patients with isthmus-dependent atrial flutter which occurred in the early post-operation period (during the same hospitalization) after open-heart surgery with the use of extracorporeal circulation. Two subjects of Group I underwent surgical treatment of coronary artery disease (CAD), five subjects were treated because of congenital or acquired valvular disease, congenital heart disorders, or the left atrium myxoma; simultaneous surgical correction of CAD and valvular procedures was performed in 7 patients. Atrial flutter developed 5.3±2.4 days (2 9 days) after the surgical intervention. RFA of cavo-tricuspid isthmus (CTI) was performed 10.4±3.3 days after the surgery (6 18 days). Group II included 20 patients with a history of surgical treatment of CAD (6 patients), surgical treatment of congenital or acquired valvular disease or congenital heart disorders (11 patients), and simultaneous surgical correction of CAD and valvular procedures (3 patients). RFA CTI was performed 4 606 months after the open-heart surgery (median: 21 months; Q25: 11.7; Q75: 68.7). Group III (control group) consisted of 151 patients with isthmus-dependent atrial flutter without history of open-heart surgery. RFA was indicated to all study subjects in accordance with the Russian Scientific Arrhythmia Society guidelines. During RFA, linear applications were attempted gradually moving the electrode from the tricuspid valve ring at intervals of 2-3 mm to the lower cave vein ostium. If they were ineffective, additional linear applications were made to connect ostia of the coronary sinus with the lower cave vein, as well as in the lateral isthmus. RFA applications were made also after the sinus rhythm recovery until bidirectional block in the right isthmus was detected. The CTI block was achieved in 174 patients of 185; the success rate was 94.1%. The CTI block was documented in 13 patients of 14 in Group I, in 18 patients of 20 in Group II, and in 143 patients of 151 in Group III (p=0.849); therefore effectiveness of the procedure did not significantly differ in different groups. The duration of the RFA CTI procedure was 73.3±33.6 min; the fluoroscopy time was 717.7±453.6 s. Thus, based on the data obtained, RFA can be considered effective in patients with isthmus-dependent atrial flutter documented shortly after open-heart surgery. The authors consider conducting RFA in isthmus-dependent atrial flutter as soon as possible after the open-heart surgery. The low number of case reports warrants further experience and clinical research.

atrial flutter, cavo-tricuspid isthmus, isthmus block, aortocoronary bypass grafting, extracorporeal circulation, radiofrequency catheter ablation

1. Кушаковский, М.С. Аритмии сердца (Расстройства сердечного ритма и нарушения проводимости. Причины, механизмы, электрофизиологическая диагностика, клиника, лечение): Руководство для врачей. - 3-е изд., испр. доп. / М.С. Кушаковский. - СПб.: ООО «Издательство Фолиант», - 2007. - 672 с.: ил.

2. Клинические рекомендации по проведению электрофизиологических исследований, катетерной аблации и применению имплантируемых антиаритмических устройств. / А.Ш. Ревишвили и др. Всероссийское научное общество специалистов по клинической электрофизиологии, аритмологии и кардиостимуляции (ВНОА), // М. МАКС Пресс - 2013. - 596 с.

3. Ардашев, А.В. Клиническая аритмология. / Под ред. проф. А.В. Ардашева - М.: ИД «Медпрактика - М», 2009. - 1220 с.

4. Granada, J. Incidence and predictors of atrial flutter in the general population. / J. Granada, W. Uribe, P.H. Chyou et al. // J Am Coll Cardiol, 2000; 36 (7): 2242-2246.

5. Артюхина, Е.А. Электрофизиологическая диагностика и интервенционное лечение аритмий после операций на открытом сердце: автореферат дисс.. доктора мед. наук (14.01.26 - сердечно-сосудистая хирургия). / Е.А. Артюхина, НЦ ССХ им. А.Н. Бакулева РАМН, Москва, 2010. - 46 с.

6. Atrial fibrillation after cardiac surgery: Where are we now? / D. Patel, Marc A. Gillinov, А. Natale. // Indian Pacing Electrophysiol J. - 2008,Oct-Dec; 8(4): 281-291.

7. Alqahtani, A.A.R. Atrial fibrillation post cardiac surgery trends toward management. / A.A.R. Alqahtani. // Heart Views. - 2010, Jun-Aug; 11(2): 57-63.

8. Zaman, A.G. Atrial fibrillation after coronary artery bypass surgery a model for preoperative risk stratification. / A.G. Zaman, R.A. Archbold, G. Helft et al. // Circulation. -2000. - Vol. 101. - P. 1403-1408.

9. Бунин, Ю.А. Трепетание предсердий: современные возможности диагностики и лечения. / Ю.А.Бунин. // Журнал «Рациональная Фармакотерапия в Кардиологии». - 2011. - 7(1): с. 57 - 64.

10. Kastor, J.A. Arrhythmias. / J.A. Kastor. // Philadelphia: W.B. Saunders company - 1994. - р. 105-44.

11. Triedman, J.K. Arrhythmias in adults with congenital heart disease. / J.K. Triedman. // Heart. - 2002. - Vol. 87. - P. 383-389.

12. Walsh, E.P. Arrhythmias in adults patients with congenital heart disease. / E.P. Walsh, F. Cecchin. // Circulation. - 2007. - Vol. 115. - P. 534-545.

13. Kammeraad, J. Predictors of sudden cardiac death after Mustard or Senning repair for transposition of the great arteries. / J. Kammeraad, C. Deurzen, N. Sreeram, M. et al. // J. Am. Coll. Cardiol. - 2004. - Vol. 44. - P. 1095-102.

14. Kanter, R.J. Radiofrequency catheter ablation of supraventricular tachycardia substrates after Mustard and Senning operations for d-transposition of the great arteries. / R.J. Kanter, J. Papagiannis, M.P. Carboni et al. // J. Am. Coll. Cardiol. - 2000. - Vol. 35. - P. 428-441.

15. Deal, B.J. Comparison of anatomic isthmus block with modified right atrial maze for late atrial tachycardia in Fontan patients. / B.J. Deal, C. Mavroudis, K. Backer et al. // Circulation. - 2002. - Vol. 106. - P. 575-579.

16. Kim W.H. Fontan conversion with arrhythmia surgery. / W.H. Kim, H.G. Lim, J.R. Lee et al. // Eur. J. Cardiothorac. Surg. - 2005. - Vol. 27. - P. 250-257.

17. Mantovan R. Supraventricular arrhythmia before and after closure atrial septal defects: spectrum, prognosis and management. / R. Mantovan, M.A. Gatzoulis, A. Pedrocco et al. // Europace. - 2003. - Vol. 5. - P. 133-138.

18. Ishii Y. Atrial tachyarrhythmias after the Maze Procedure incidence and prognosis. / Y. Ishii, M.J. Gleva, M.C. Gamache et al. // Circulation. - 2004. - Vol. 110.-II-164-II-168.

19. Mori S. Atrial flutter after coronary artery bypass grafting: proposed mechanism as illuminated by independent predictors. / S. Mori, G. Fujii, H. Ishida et al. // J. Ann Thorac Cardiovasc Surg Vol. 9, No. 1 (2003) р. 50-56.

20. Hashimoto K. Influence of clinical and hemodynamic variables on risk of supraventricular tachycardia after coronary artery bypass. / K. Hashimoto, D.M. Ilstrup, H.V. Schaff. // J Thorac Cardiovasc Surg 1991; 101: 56-65.

21. Creswell, L.L. Hazards of postoperative atrial arrhythmias. / L.L. Creswell, R.B. Schuessler, M. Rosenbloom, J.L. Cox. // Ann Thorac Surg 1993; 56: 539-49.

22. Pires, L.A. Arrhythmias and conduction disturbances after coronary artery bypass graft surgery: epidemiology, management and prognosis. / L.A. Pires, A.B. Wagshal, R. Lancey, S.K. Huang. // Am Heart J 1995; 129: 799-808.

23. Aranki, S.F. Predictor of atrial fibrillation after coronary artery surgery. / S.F. Aranki, D.P. Shaw, D.H. Adams et al. // Circulation 1996; 94: 390-7.

24. Matthew, J.P. Atrial fibrillation following coronary artery bypass graft surgery. / J.P. Matthew, R. Parks, J.S. Savino et al. // JAMA 1996; 276: 300-6.

25. Leitch, J.W. The importance of age as a predictor of atrial fibrillation and flutter after coronary artery bypass grafting. / J.W. Leitch, D. Thomson, D.K. Baird et al. // J Thorac Cardiovasc Surg 1990; 100: 338-342.

26. Asher, C.R. Analysis of risk factors for development of atrial fibrillation early after cardiac valvular surgery. / C.R. Asher, D.P. Miller, R.A. Grimm et al. // Am J Cardiol 1998; 82: 892-895.

27. Гринь, В.К. Правопредсердные re-entry тахикардии после операций с искусственным кровообращением. / В.К. Гринь, Т.В. Кравченко, С.И. Эстрин. Институт неотложной и восстановительной хирургии им. В.К. Гусака АМН Украины, Донецк - Серце і судини. -2009 г. - N 2. - С. 93-100.

28. Anne, W. Ablation of postsurgical intraatrial reentrant tachycardia. / W. Anne, H. Rensburg, J. Adams et al. // Eur. Heart J. - 2002. - Vol. 23. - P. 1609-1612.

29. Verna, A. Importance of ablating all potential right atrial flutter circuit in postcardiac surgery patients. / A. Verna, N. Marrouche, N. Seshadri, A. Natale. // J. Am. Coll. Cardiol. - 2004. - Vol. 44. - P. 409-414.

30. Triedman, J.K. Radiofrequency ablation of intraatrial reentrant tachycardia after surgical palliation of congenital heart disease. / J.K. Triedman, J.P. Saul, S.N. Weindling, E.P. Walsh. // Circulation. - 1995. - Vol. 91. - Р. 707-714.

31. Chan, D.P. Importance of atrial flutter isthmus in postoperative intra-atrial reentrant tachycardia. / D.P. Chan, G.F. Van Hare, J.A. Mackall et al. // Circulation. 2000; 102: 1283-1289

32. Макарова, Н.В. Трепетание предсердий: причины неэффективного лечения методом радиочастотной катетерной аблации. / Н.В. Макарова, С.С. Дурманов, А.В. Козлов и др. // Вестник аритмологии. - 2012. - № 69. - С. 57-64.

33. Podrid, P.J. Prevention of postoperative atrial fibrillation: what is the best approach? / P.J. Podrid. // J Am Coll Cardiol 1999; 34: 340-2.

34. Покушалов, Е.А. Катетерная аблация трепетания предсердий после хирургической коррекции многоклапанного порока. / Е.А. Покушалов, А.Н. Туров, П.Л. Шугаев и др. // Вестник аритмологии. - 2006. - № прил. А. - С. 111.