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| Reverse Remodeling of Atrioventricular Node After Catheter Ablation of Longstanding Atrial Flutter with Prolonged Pause |
| 고려대학교 심장내과¹ 부천세종병원 심장내과² Utah Valley Medical Center³ |
| 임홍의¹, 장진근¹, 나진오¹, 박재형¹, 박재석¹, 최철웅¹, 최종일¹, 김성환¹, 김진원¹, 김응주¹, 나승운¹, 박희남¹, 박창규¹, 서홍석¹, 오동주¹, 김진석², 박상원², 황준³, 김영훈¹ |
Background: Symptomatic prolonged pauses (long R-R interval) during atrial flutter (AFL) are used to be treated by pacemaker implantation. We investigated clinical outcome in patients with longstanding AFL with slow ventricular response who underwent ablation of AFL.
Methods: Seven patients (mean age: 64.9±11.4 yrs, male: 5) with longstanding (≥1 years) AFL and prolonged pauses (≥3 seconds) underwent successful catheter ablation of AFL. Patients with significant structural heart disease or prior medications affecting atrioventricular (AV) node function were excluded. AV node function was assessed by electrophysiologic test immediately after ablation (at baseline), and by 24-hour ambulatory monitoring and exercise testing at 3 months.
Results: All patients were identified to have cavotricuspid isthmus (CTI) dependent AFL and underwent bidirectional block of the CTI. After ablation, there was a significant increase in the mean heart rate, maximum heart rate, and heart rate range at 3 months. None have recurrent AFL during follow up of 9±8 months. 5 patients (71.4%) did not have any symptoms attributable to bradycardia or prolonged pauses on ambulatory monitoring. Two patients (28.6%) were highly symptomatic due to associated sinus node dysfunction (sinus pause > 3 sec) during follow up, subsequently underwent pacemaker implantation. There were no differences in the AV block cycle length, AV node effective refractory period, and HV interval between patients with and without pacemaker implantation. However, patients without pacemaker implantation had a longer AH interval (127.8±11.3 vs. 58.0±2.8, P<0.001) and a shorter sinus node recovery time (SNRT, 4.1±2.1 vs. 19.9±5.6 seconds, P=0.002) compared with patients with pacemaker implantation.
Conclusions: Slow ventricular response during the longstanding AFL may result from the chronic concealment of AV node within the tachycardia circuit or hypervagotonia, and it can be improved by curative ablation of typical AFL. Pacemaker implantation needs to be considered only in patients with associated sinus node dysfunction.
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