Pattern of isthmus conduction recovery using open cooled and solid large-tip catheters for radiofrequency ablation of typical atrial flutter

INTRODUCTION: Open cooled-tip and solid 8-mm-tip catheters have demonstrated safety and effectiveness for radiofrequency current (RFC) ablation of typical atrial flutter (AFL). However, data from prospective and randomized studies in this setting are lacking.

METHODS AND RESULTS: One hundred thirty consecutive patients (104 men; 61 +/- 11 years) with AFL were randomized to undergo RFC catheter ablation either using a solid 8-mm-tip catheter (group A, 65 degrees C, 70 W, 60 s) or an open irrigated-tip catheter (group B, 65 degrees C, 50 W, 60 s, 17 mL/min flow). Endpoint was bidirectional conduction isthmus block. In cases of repeated (two times) transient isthmus block, the catheter was changed (crossed over) to the catheter used in the other randomization arm, but patients remained in the original group following intention-to-treat analysis. The selected endpoint could be achieved in all patients after 12 +/- 6 RFC pulses in group A and 10 +/- 7 RFC pulses in group B (P = 0.11). Procedure times were longer (159 +/- 38 min vs 138 +/- 37 min, P = 0.002) and x-ray exposures higher in group A (fluoroscopy time 25 +/- 17 min vs 21 +/- 10 min, P = 0.08; x-ray dosage 3,133 +/- 2,576 cGy.cm2 vs 2,326 +/- 1,405 cGy.cm2, P = 0.03). Transient isthmus block was observed in 23 group A patients and 12 group B patients (P = 0.03). Onset time of transient isthmus block ranged from 0.5 to 27 minutes. Repeated transient isthmus block occurred in 8 of the 23 patients in group A after 19 +/- 3 RFC applications. After crossover to the cooled-tip catheter, the endpoint was reached another 5 +/- 1 RFC pulses. In group B, all patients could be treated without change of ablation catheter. After a follow-up of 14 +/- 2 months, 2 patients (3%) in group A and 1 patient (1.5%) in group B presented with AFL recurrence.

CONCLUSION: Open cooled-tip catheters are more effective than solid large-tip catheters for AFL ablation. The greater effectiveness is evident in cases showing repeated conduction recovery within the cavotricuspid isthmus. Primary use of open irrigated-tip catheters should be considered for AFL ablation.