We searched PubMed for reports published between 1980, and 2012, with the search terms “atrial fibrillation”, “atrial flutter”, and “atrial tachycardia” in combination with the term “ablation”. We mainly selected publications from the past 5 years, but did not exclude frequently referenced and highly regarded older publications. We also pursued articles referenced in primary sources and their relevant citations and selected those we judged relevant.
SeriesCatheter ablation of atrial arrhythmias: state of the art
Introduction
Atrial arrhythmias include a range of different rhythm disturbances that encompass almost the full range of arrhythmia mechanisms. The three most frequently encountered arrhythmias, which are the focus of this review, are focal atrial tachycardia, atrial flutter, and atrial fibrillation. Generally, these arrhythmias respond poorly to antiarrhythmic drugs, and patients frequently have recurring and at times debilitating symptoms. Throughout the past decade, major technological advances in cardiac electrophysiology have brought catheter ablation to the forefront of treatment algorithms for these arrhythmias. In this Series paper, we provide an overview of the underlying mechanisms, relevant anatomy, and catheter-based treatment of these arrhythmias.
Section snippets
Classification of atrial arrhythmias
The nomenclature surrounding the classification of atrial arrhythmias continues to be unclear. Broadly, organised atrial tachycardias can be classified into two categories according to the arrhythmia mechanism: focal or macro-re-entry. Atrial fibrillation is a disorganised rhythm and its classification according to underlying mechanism is still evolving.
Focal atrial tachycardias are defined by early atrial activation from a discrete site with radial spread to the periphery.1 They can be
ECG considerations
ECG cannot reliably distinguish tachycardia mechanism. No effective rate cutoff exists to differentiate focal atrial tachycardia from atrial flutter, and when viewing a 12-lead ECG snapshot, it can be difficult to distinguish between atrial fibrillation with coarse fibrillatory waves and atrial flutter. The distinction can be made with a careful analysis of P wave morphology and rate, which should be constant in atrial flutter and variable in atrial fibrillation.
General considerations
Focal atrial tachycardia is classified as a type of supraventricular tachycardia. It is the least common form of this arrhythmia (after atrioventricular node re-entry and atrioventricular re-entry tachycardia) and accounts for just 10–15% of patients referred for catheter ablation of supraventricular tachycardia.4 Although generally benign, up to 25% of patients will present with frequent paroxysms or incessant activity, with a third of these patients eventually developing a
General considerations
Atrial flutter represents a heterogeneous group of arrhythmias defined mechanistically by the presence of a large circuit around a central obstacle, which can be a fixed anatomical structure or a functional electrophysiological line of block. Generally, the unique anatomy of the atrium is an important determinant of the location of a flutter circuit. The most common form is best known as typical atrial flutter and is characterised by the presence of classic saw-tooth flutter waves in the
General considerations
Over the past decade, catheter ablation has evolved to become a routine procedure for selected patients with atrial fibrillation. This section will focus on the underlying mechanisms of atrial fibrillation in the context of catheter ablation, the common techniques, and the outcomes of these techniques.
Guidelines from the American College of Cardiology, American Heart Association, and European Society of Cardiology recommend catheter ablation for patients with atrial fibrillation who remain
Conclusion
Catheter ablation is now at the forefront of the treatment algorithm for a broad range of atrial arrhythmias. In patients with focal atrial tachycardia and typical atrial flutter, it is a first line therapy with efficacy in excess of 90%. For patients with a range of complex atypical flutters, it is a highly effective approach in those not readily controlled with antiarrhythmic drugs. For patients with previous atrial surgery or more complex congenital heart disease, late flutter recurrence or
Search strategy and selection criteria
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