The Never Old-Fashioned Right Atrial Flutter Revisited

The Never Old-Fashioned Right Atrial Flutter Revisited | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL Journal of Cardiovascular Electrophysiology This is a preprint and has not been peer reviewed. Data may be preliminary. 17 August 2025 V1 Latest version Share on The Never Old-Fashioned Right Atrial Flutter Revisited Authors : Antoine Da Costa 0000-0003-3302-9988 [email protected] and Karim Benali Authors Info & Affiliations https://doi.org/10.22541/au.175543206.68950059/v1 Published Journal of Cardiovascular Electrophysiology Version of record Peer review timeline 272 views 149 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Although major investigations on the AF risk after AFL ablation have been published, the natural history of right AFL after cardioversion is much less understood. The authors sought to the largest historical cohort on the subject in order to establish the true risk of AFL and AF recurrence after AFL DCCV. Overall, 860 individuals with atrial arrhythmias were included and underwent their first DCCV. The median time to recurrence was 3.4 months in the AF cohort (n=572), and 1.7 years in the AFL cohort (n=288). The overall recurrence of atrial arrhythmias was 96.0% for the AF group and 78.8% for the AFL group (p<0.001). In the AF group, most of the recurrent rhythm was AF (92.7%), while only a small percentage was AFL (7.3%). Conversely, the AFL cohort showed recurrence of AF in only 32.6% of cases and 67.4% reverted back to AFL. AFL recurrences represented 53% of the cases within the entire AFL population. the authors created a clinical predictive risk score for predicting recurrence risk after the first DCCV in this pure AFL population. the REAL-PDX risk score stratified by ≥3 vs. <3 in the AFL validation cohort (n=112) showed a significantly shorter median time to recurrence (125 vs. 800 days; p<0.001) and a higher risk of recurrence of atrial arrhythmia (HR: 3.74; 95% CI [1.93-7.24]).This study will certainly remain a benchmark in the field of right AFL natural history after DCCV. INVITED EDITORIAL Antoine Da Costa, MD, PhD and Karim Benali, MD. From the Division of Cardiology, Jean Monnet University (ADC, KB), Saint-Etienne, France. Address for Correspondence: Professor Antoine Da Costa, Service de Cardiologie, Hôpital Nord, Centre Hospitalier Universitaire de Saint-Etienne, F-42055 Saint-Etienne Cedex 2. Tel.: +33 (0)4 77 82 82 42; fax: +33 (0)4 77 82 81 64; email: [email protected] The Never Old-Fashioned Right Atrial Flutter Revisited Historically, the typical right atrial flutter (AFL) was defined by its specific electrocardiogram (ECG) characteristics (“saw-tooth” pattern of P waves in the inferior leads), but the classification as typical or atypical is based on its electrophysiological mechanism [1, 2]. Typical right AFL involves a macro-reentry circuit around the tricuspid annulus, which is characterized by organized atrial activity. Atypical flutter describes a wide variety of reentrant circuits in either the left or right atrium, that do not involve the cavotricuspid isthmus (CTI), and can be difficult to diagnose on ECG alone [2]. For the typical right AFL, new insights into the conduction and substrate variability of right atrial macro-reentrant tachycardia were recently gained using ultra‐high‐resolution mapping [3]. The mechanistic posterior sinus venosus and Eustachian ridge block lines were confirmed and a systematic slowing down in both the entrance to and exit from the CTI was demonstrated [3]. Right AFL frequently coexists with atrial fibrillation (AF). They share a close mechanistic relationship, with one rhythm often preceding or transitioning into the other [4]. If radiofrequency ablation (RFA) is the standard of care for right AFL treatment, the main weakness of the procedure is that during extended follow-up, AF emerges in about half of the patients, mostly in those with a history of AF [5]. Historically, two randomized studies have demonstrated the superiority of right AFL RFA compared with direct current cardioversion (DCCV) combined with antiarrhythmic drugs, but this approach did not prevent the AF risk [Table I] [6, 7]. For example, the multicenter randomized LADIP study demonstrated that AFL recurrence was significantly reduced compared with DCCV combined with amiodarone (3.8% vs 29.5%; p<0.0001), but the occurrence of significant AF lasting over 10 minutes was equivalent in both groups (25% versus 18%; p=0.3) [6]. In a smaller study, Natale et al. investigated recurrent AFL and found similar results, with 6.4% of AFL recurrence and 29% of AF occurrence after AFL ablation [7]. These findings suggest that eliminating AFL might delay AF, but does not prevent it [5]. Although major investigations on the AF risk after AFL ablation have been published, the natural history of right AFL after cardioversion is much less understood [8-11]. Moreover, populations are frequently combined (AFL and AF together) in studies, which prevents a clear reading and interpretation of the results [8-12]. Unfortunately, only a few small retrospective studies have been reported on this subject [8-11] [Table II]. The only exploitable data are the high risk of recurrence of all atrial arrhythmias combined and the higher risk of AFL recurrence after medical treatment, which was close to 50% [8-11]. Doh CY et al. deserve credit for investigating the largest historical cohort on the subject in order to establish the true risk of AFL and AF recurrence after AFL DCCV [12] [Figure 1]. The data were collected from individuals with atrial arrhythmias who underwent DCCV in the Veterans Affairs EP database from 2002 to 2016. Overall, 860 individuals with atrial arrhythmias were included and underwent their first DCCV. The median time to recurrence was 3.4 months in the AF cohort (n=572), and 1.7 years in the AFL cohort (n=288). Of the 860 patients, 90.2% had recurrence during the follow-up period of about 16 years [12]. The overall recurrence of atrial arrhythmias was 96.0% for the AF group and 78.8% for the AFL group (p<0.001) [12]. Several important information were highlighted in this study. The predominant recurrent rhythm was different between the two cohorts. In the AF group, most of the recurrent rhythm was AF (92.7%), while only a small percentage was AFL (7.3%). Conversely, the AFL cohort showed recurrence of AF in only 32.6% of cases and 67.4% reverted back to AFL. AFL recurrences represented 53% of the cases within the entire AFL population [12]. This analysis confirms the direct relationship between the two arrhythmias, as well as the fact that both arrhythmias are progressive and evolutive diseases. This clinical investigation also argues in favor of first-line ablation in patients with AFL. Indeed, the risk of AFL recurrence over time (53%) was higher than expected, and the lack of efficacy of antiarrhythmic agents has clearly been demonstrated in randomized studies and in this large cohort [6, 7, 12]. Additionally, attention must be paid to the anticoagulant strategies and recurrence monitoring must be implemented even in AFL patients. Interestingly, pure AF populations are exposed at a low risk of right AFL, minus 10% over a long period of time. Consequently, systematic CTI ablation does not seem necessary when ablating AF [12]. Finally, the authors created a clinical predictive risk score for predicting recurrence risk after the first DCCV in this pure AFL population [12] [Figure 1]. They elegantly divided the AFL population (n=288) into derivation (60%) and validation (40%) cohorts. The Cox proportional hazard analysis of the AFL derivation cohort (n=176) revealed that chronic kidney disease (HR: 2.42; 95% CI [1.41-4.14]), every 1 year of older age (HR: 1.03; 95% CI [1.01-1.06]), left atrial (LA) dilation (HR: 1.60; [1.00- 2.55]; p1 year since diagnosis (HR: 2.10; 95% CI [1.22-3.61]) were independently associated with an increased recurrence risk [12]. Interestingly, body mass index, obstructive sleep apnea, hypertension, cerebrovascular disease, chronic obstructive pulmonary disease, and heart failure did not affect the recurrence hazard. The statistical power of the study certainly influenced the results. The new element was the elaboration of the REAL-PDX (REnal disease, Age ≥65, LA dilation, Prior DX) risk score to predict AFL recurrence. This risk score was built using the identified predictive factors in the derivation cohort, with one point attributed per significant identified factor. Consequently, the REAL-PDX risk score stratified by ≥3 vs. <3 in the AFL validation cohort (n=112) showed a significantly shorter median time to recurrence (125 vs. 800 days; p<0.001) and a higher risk of recurrence of atrial arrhythmia (HR: 3.74; 95% CI [1.93-7.24]). Thus, the REAL-PDX risk score can predict a higher risk of recurrence, which can help medical practitioners guide the anticoagulation, an early CTI ablation approach, or perhaps the decision to perform pulmonary vein isolation. These relevant results remain of clinical interest, especially to electrophysiologists when they explain to patients their decision to perform first-intent AFL and/or AFib ablation. In addition, these data on populations with AFL are very rare and valuable. The methodology used is original and robust even if the data extracted were retrospective. This study will certainly remain a benchmark in the field of right AFL natural history after DCCV. The authors have to be congratulated for this achievement. References 1. Puech P, Latour H, Grolleau R. [Flutter and his limits]. Arch Mal Cœur Vaiss 1970; 63: 116 –144. 2. Saoudi N, Cosıo F, Waldo A, Chen SA, Iesaka Y, Lesh M, Saksena S, Salerno J, Schoels W, Working Group of Arrhythmias of the European of Cardiology and the North American Society of Pacing and Electrophysiology. A classification of atrial flutter and regular atrial tachycardia according to electrophysiological mechanisms and anatomical bases; a Statement from a Joint Expert Group from The Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Eur Heart J 2001; 22: 1162 –1182 (Review). 3. Yvorel C, Da Costa A, Lerebours C et al. Comparison of clockwise and counterclockwise right atrial flutter using high-resolution mapping and automated velocity measurements. J Cardiovasc Electrophysiol 2021 Aug; 32 (8):2127-2139. 4. Waldo AL. Mechanisms of atrial flutter and atrial fibrillation: distinct entities or two sides of a coin? Cardiovasc Res. 2002 May; 54(2): 217-29. 5. Ellis K, Wazni O, Marrouche N et al. Incidence of Atrial Fibrillation Post-Cavotricuspid Isthmus Ablation in Patients with Typical Atrial Flutter: Left-Atrial Size as an Independent Predictor of Atrial Fibrillation Recurrence. J. Cardiovasc. Electrophysiol. 2007; 18:799-802. 6. Da Costa A, Thévenin J, Roche F, et al. Results from the Loire-Ardèche-Drôme-Isère-Puy-de-Dôme (LADIP) trial on atrial flutter, a multicentric prospective randomized study comparing amiodarone and radiofrequency ablation after the first episode of symptomatic atrial flutter. Circulation. 2006; 114: 1676–81. 7. Natale A, Newby KH, Pisanó E, et al. Prospective randomized comparison of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter. J Am Coll Cardiol. 2000; 35: 1898–904. 8. Suttorp MJ, Kingma JH, Koomen EM, van ’t Hof A, Tijssen JG, Lie KI. Recurrence of paroxysmal atrial fibrillation or flutter after successful cardioversion in patients with normal left ventricular function. Am J Cardiol. 1993; 71: 710–3. 9. Crijns HJ, Van Gelder IC, Tieleman RG, et al. Long-term outcome of electrical cardioversion in patients with chronic atrial flutter. Heart. 1997; 77: 56–61. 10. Dahlin J, Svendsen P, Gadsbøll N. Poor maintenance of sinus rhythm after electrical cardioversion of patients with atrial fibrillation or flutter: a 5-year follow-up of 268 consecutive patients. Scand Cardiovasc J. 2003; 37: 324–8. 11. Elesber AA, Rosales AG, Herges RM, et al. Relapse and mortality following cardioversion of new onset vs. recurrent atrial fibrillation and atrial flutter in the elderly. Eur Heart J. 2006; 27:854–60. 12. Doh CY, Phan F, Dalouk K et al. Atrial Arrhythmia Recurrence after First Direct-Current Cardioversion in People with Atrial Flutter. J cardiovasc Electrophysiol In press. Table I. Randomized studies on atrial flutter: RFA vs. DCCV plus antiarrhythmic agents Natale A et al. 2000 [7] n= 61 21 6% vs. 93% p<0.01 29% vs. 50% p<0.05 Da Costa A et al. [6] n=104 13 3.8% vs. 29.5% p<0.0001 25% vs.18% p=0.3 AFib: atrial fibrillation; AFL: atrial flutter; DCCV: direct current cardioversion; FU: follow-up; RFA: radiofrequency ablation. Table II. Studies on direct current cardioversion (DCCV) in atrial flutter Studies Suttorp MJ et al. 1993 [8] 21 23 48%* 48%* Crijns HJ et al. 1997 [9] 50 12 53% ND Dalhin J et al. 2003 [10] 67 12 25%* 25%* Elesber AA et al. 2006 [11] 126 3.5 66.9%* 66.9%* Doh Cy et al. 2025 [12] 288 19 67.4% 32.6% AFib: atrial fibrillation; AFL: atrial flutter; FU: follow-up; ND: not detected. *Recurrence of the recurrences of AF and Flutter were not differentiated. Information & Authors Information Version history V1 Version 1 17 August 2025 Peer review timeline Published Journal of Cardiovascular Electrophysiology Version of Record 7 Sep 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Journal of Cardiovascular Electrophysiology Keywords basic: atrial fibrillation/atrial arrhythmias clinical: catheter ablation – atrial flutter clinical: electrophysiology – atrial arrhythmias Authors Affiliations Antoine Da Costa 0000-0003-3302-9988 [email protected] Jean Monnet University View all articles by this author Karim Benali Jean Monnet University Saint-Etienne University Institute of Technology View all articles by this author Metrics & Citations Metrics Article Usage 272 views 149 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Antoine Da Costa, Karim Benali. The Never Old-Fashioned Right Atrial Flutter Revisited. Authorea . 17 August 2025. DOI: https://doi.org/10.22541/au.175543206.68950059/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. 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