Clinical and Electrophysiological Predictors of Isthmus Dependency in Atrial Flutter
Abstract
1. Introduction
2. Materials and Methods
2.1. Study Population
2.2. EPS and Ablation
2.3. ECG Analysis
2.4. Statistical Analysis
3. Results
3.1. Baseline Characteristics
3.1.1. Baseline Characteristics of Patients with Type I ECGs and Type II ECGs
3.1.2. Baseline Characteristics of Patients with CTI-Dependent and Non-CTI-Dependent AFL
3.1.3. Baseline Characteristics of Subgroups Based on CTI Dependence and ECG Records
3.2. Characteristics of the ECG and Electrophysiological Parameters Between Subgroups
3.3. Prediction Models for CTI-Dependent AFL and Type I ECG
3.4. Prediction Models for CTI-Dependent AFL and Type II ECG
4. Discussion
Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Abbreviations
AAs | Antiarrhythmics |
AAT | Antiarrhythmic therapy |
AF | Atrial fibrillation |
AFL | Atrial flutter |
ANOVA | Analysis of variance |
AUC | Area under the curve |
BMI | Body mass index |
Bpm | Beats per minute |
CCW | Counterclockwise |
CL | Cycle length |
COPD | Chronic obstructive pulmonary disease |
CS | Coronary sinus |
CTI | Cavotricuspid isthmus |
CW | Clockwise |
Df | Degrees of freedom |
ECG | Electrocardiogram |
EPS | Electrophysiological study |
ICD | International classification of diseases |
IVC | Inferior vena cava |
LA | Left atrial |
LAO | Left anterior oblique |
LRA | Low right atrium |
N/A | Not applicable |
OAC | Oral anticoagulation |
OR | Odds ratio |
OSAS | Obstructive sleep apnea syndrome |
PM | Pacemaker |
PPI | Post-pacing interval |
PVI | Pulmonary vein isolation |
RA | Right atrial |
ROC | Receiver operator characteristics |
SD | Standard deviation |
Sig. | Significance |
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Type I ECG | Type II ECG | Total Participants | |
---|---|---|---|
CTI-dependent AFL | 242 (63.1) | 52 (13.6) | 294 (76.7) |
Non-CTI-dependent AFL | 26 (6.8) | 63 (16.4) | 89 (23.2) |
Total participants | 268 (70.0) | 115 (30.0) |
Baseline Characteristics | All Patients (n = 383) |
---|---|
Age [years], mean ± SD | 69.3 ± 11.2 |
Male, n (%) | 300 (78.3) |
BMI [kg/m2], mean ± SD | 28.1 ± 5.7 |
Coronary heart disease, n (%) | 149 (39.2) |
Arterial hypertension, n (%) | 275 (71.8) |
Hyperlipoproteinemia, n (%) | 201 (52.5) |
Diabetes mellitus, n (%) | 89 (23.3) |
Chronic obstructive pulmonary disease, n (%) | 45 (11.7) |
Obstructive sleep apnea syndrome, n (%) | 22 (5.7) |
Pulmonary hypertension, n (%) | 27 (7.0) |
Stroke, n (%) | 36 (9.4) |
Oral anticoagulation prior to ablation, n (%) | 214 (58.0) |
CHA2DS2-VASc score, mean ± SD | 3.0 ± 1.7 |
Antiarrhythmic drugs
| 31 (8.4) 281 (76.2) 24 (6.5) |
Prior atrial fibrillation, n (%) | 145 (37.9) |
Prior PVI, n (%) | 35 (9.1) |
Prior LA/RA ablation (without PVI), n (%) | 13 (3.4) |
Prior heart surgery, n (%) | 63 (16.4) |
Type I ECG | Type II ECG | p-Value | |
---|---|---|---|
Total, n (%) | 268 (70.0) | 115 (30.0) | N/A |
Age [years], mean ± SD | 67.8 ± 10.9 | 73.0 ± 11.1 | <0.001 |
Male, n (%) | 220 (82.1) | 80 (69.6) | 0.006 |
BMI [kg/m2], mean ± SD | 28.1 ± 5.7 | 28.1 ± 5.8 | 0.920 |
Coronary heart disease, n (%) | 97 (36.5) | 52 (45.6) | 0.094 |
Arterial hypertension, n (%) | 185 (69.0) | 90 (78.3) | 0.066 |
Hyperlipoproteinemia, n (%) | 136 (50.7) | 65 (56.5) | 0.300 |
Diabetes mellitus, n (%) | 51 (19.1) | 38 (33.0) | 0.003 |
Chronic obstructive pulmonary disease, n (%) | 33 (12.3) | 12 (10.4) | 0.601 |
Obstructive sleep apnea syndrome, n (%) | 15 (5.6) | 7 (6.1) | 0.850 |
Pulmonary hypertension, n (%) | 17 (6.3) | 10 (8.7) | 0.410 |
Stroke, n (%) | 18 (6.7) | 18 (15.7) | 0.006 |
Oral anticoagulation prior to ablation, n (%) | 148 (56.5) | 66 (61.7) | 0.359 |
CHA2DS2-VASc score, mean ± SD | 2.7 ± 1.6 | 3.8 ± 1.7 | <0.001 |
Antiarrhythmic drugs
| 25 (9.5) 193 (73.7) 17 (6.5) | 6 (5.6) 88 (82.2) 7 (6.5) | 0.216 0.079 0.985 |
Prior atrial fibrillation, n (%) | 93 (34.7) | 52 (45.2) | 0.052 |
Prior PVI, n (%) | 21 (7.8) | 14 (12.2) | 0.177 |
Prior heart surgery, n (%) | 39 (14.6) | 24 (20.9) | 0.126 |
CTI-dependent atrial flutter, n (%) | 242 (90.3) | 52 (45.2) | <0.001 |
CTI | Non-CTI | p-Value | |
---|---|---|---|
Total, n (%) | 294 (76.7) | 89 (23.2) | n/A |
Age [years], mean ± SD | 67.9 ± 11.1 | 74.1 ± 10.1 | <0.001 |
Male, n (%) | 247 (84.0) | 53 (59.6) | <0.001 |
BMI [kg/m2], mean ± SD | 28.0 ± 5.3 | 28.5 ± 7.1 | 0.544 |
Coronary heart disease, n (%) | 107 (36.6) | 42 (47.7) | 0.478 |
Arterial hypertension, n (%) | 201 (68.4) | 74 (83.1) | 0.007 |
Hyperlipoproteinemia, n (%) | 147 (50.0) | 54 (60.7) | 0.077 |
Diabetes mellitus, n (%) | 65 (22.2) | 24 (27.0) | 0.350 |
Chronic obstructive pulmonary disease, n (%) | 38 (12.9) | 7 (7.9) | 0.194 |
Obstructive sleep apnea syndrome, n (%) | 18 (6.1) | 4 (4.5) | 0.563 |
Pulmonary hypertension, n (%) | 21 (7.1) | 6 (6.7) | 0.897 |
Stroke, n (%) | 23 (7.8) | 13 (14.6) | 0.055 |
Oral anticoagulation prior to ablation, n (%) | 161 (55.9) | 53 (65.4) | 0.125 |
CHA2DS2-VASc score, mean ± SD | 2.8 ± 1.7 | 3.9 ± 1.7 | <0.001 |
Antiarrhythmic drugs
| 25 (8.7) 210 (72.9) 18 (6.3) | 6 (7.4) 71 (87.7) 6 (7.4) | 0.751 0.006 0.709 |
Prior atrial fibrillation, n (%) | 100 (34.0) | 45 (50.6) | 0.005 |
Prior PVI, n (%) | 17 (5.8) | 18 (20.2) | <0.001 |
Prior heart surgery, n (%) | 49 (16.7) | 14 (15.7) | 0.835 |
ECG, type I, n (%) | 242 (82.3) | 26 (29.2) | <0.001 |
CTI + Type I ECG | Non-CTI + Type I ECG | CTI + Type II ECG | Non-CTI + Type II ECG | p-Value | |
---|---|---|---|---|---|
Total, n (%) | 242 (63.1) | 26 (6.8) | 52 (13.6) | 63 (16.4) | N/A |
Age [years], mean ± SD | 67.4 ± 10.7 *,*** | 71.1 ± 11.9 * | 70.1 ± 12.6 # | 75.4 ± 9.0 ***,# | 0.001 |
Male, n (%) | 204 (84.3) **,*** | 16 (61.5) ** | 43 (82.7) * | 37 (58.7) ***,* | 0.001 |
BMI [kg/m2], mean ± SD | 28.0 ± 5.4 | 29.6 ± 7.9 | 28.2 ± 4.4 | 28.0 ± 6.8 | 0.600 |
Coronary heart disease, n (%) | 85 (35.1) | 14 (53.8) | 24 (46.2) | 28 (41.9) | 0.117 |
Arterial hypertension, n (%) | 165 (68.2) * | 20 (76.9) | 36 (69.2) | 54 (85.7) * | 0.044 |
Hyperlipoproteinemia, n (%) | 119 (49.2) | 17 (65.4) | 28 (53.8) | 37 (58.7) | 0.259 |
Diabetes mellitus, n (%) | 49 (20.2) *,** | 2 (7.7) # | 16 (30.8) * | 22 (34.9) **,# | 0.013 |
COPD, n (%) | 31 (12.8) | 2 (7.7) | 7 (13.5) | 5 (7.9) | 0.638 |
OSAS, n (%) | 13 (5.4) | 2 (7.7) | 5 (9.6 | 2 (3.2) | 0.505 |
Pulmonary hypertension, n (%) | 15 (6.2) | 2 (7.7) | 6 (11.5) | 4 (6.3) | 0.617 |
Stroke, n (%) | 16 (6.7) * | 2 (7.7) | 7 (13.5) | 11 (17.5) * | 0.047 |
OAC prior ablation, n (%) | 132 (55.5) | 16 (61.5) | 29 (55.8) | 37 (64.9) | 0.458 |
CHA2DS2-VASc score, mean ± SD | 2.6 ± 1.6 *,***,### | 3.3 ± 1.5 * | 3.4 ± 1.8 ***,# | 4.2 ± 1.6 #,### | 0.001 |
Antiarrhythmic drugs
| 22 (9.2) 170 (70.2) *,# 16 (6.6) | 3 (12.5) 23 (95.8) * 1 (4.2) | 3 (5.8) 40 (76.9) 2 (3.8) | 3 (5.3) 48 (84.2) # 5 (8.8) | 0.591 0.013 0.734 |
Prior atrial fibrillation, n (%) | 79 (32.6) *,# | 14 (53.8) * | 21 (40.4) | 31 (49.2) # | 0.029 |
Prior PVI, n (%) | 12 (5.0) *,*** | 9 (34.6) *** | 5 (9.6) | 9 (14.3) * | 0.001 |
Prior heart surgery, n (%) | 33 (13.6) *** | 6 (23.1) | 16 (30.8) *** | 8 (12.7) | 0.005 |
Total | CTI + Type I ECG | Non-CTI + Type I ECG | CTI + Type II ECG | Non-CTI + Type II ECG | p-Value | |
---|---|---|---|---|---|---|
ECG characteristics | ||||||
Heart rate [bpm], mean ± SD | 98.2 ± 31.3 | 96.6 ± 32.5 | 98.7 ± 33.3 | 98.8 ± 32.7 | 103.6 ± 29.4 | 0.461 |
QRS [ms], mean ± SD | 113.0 ± 32.2 | 112.4 ± 32.5 | 110.5 ± 34.8 | 120.4 ± 32.4 | 110.4 ± 29.2 | 0.315 |
Atrial CL [ms], mean ± SD | 234.3 ± 39.8 | 232.6 ± 36.0 | 224.6 ± 31.3 *,# | 250.6 ± 44.1 * | 231.1 ± 49.9 # | 0.023 |
Atrial CL > 245 ms, n (%) | 121 (31.7) | 69 (28.5) *** | 6 (23.1) ** | 28 (53.8) ***,** | 18 (29.0) | <0.001 |
Ventricular PM stimulation, n (%) | 23 (6.0) | 13 (5.4) | 2 (7.7) | 6 (11.5) | 2 (3.2) | 0.286 |
EPS characteristics | ||||||
Atrial CL [ms], mean ± SD | 244.8 ± 33.7 | 241.6 ± 32.2 ** | 238.0 ± 22.4 * | 264.7 ± 36.4 **,* | 243.1 ± 35.6 | 0.001 |
Atrial CL > 245 ms, n (%) | 163 (45.2) | 97 (40.1) **,* | 9 (39.1) | 35 (71.4) **,* | 22 (37.3) | 0.001 |
Odds Ratio | 95% Confidence Interval | p-Value | |
---|---|---|---|
Age [years] | 0.965 | 0.924–1.007 | 0.100 |
Age > 75 years | 0.600 | 0.259–1.389 | 0.233 |
Male | 3.356 | 1.416–7.937 | 0.006 |
Body mass index [kg/m2] | 0.960 | 0.906–1.019 | 0.180 |
Arterial hypertension | 0.643 | 0.248–1.665 | 0.363 |
Hyperlipoproteinemia | 0.512 | 0.220–1.194 | 0.121 |
Diabetes mellitus | 3.062 | 0.700–13.402 | 0.137 |
Coronary heart disease | 0.464 | 0.205–1.048 | 0.065 |
CHA2DS2VASc score [points] | 0.793 | 0.621–1.013 | 0.063 |
AAT with beta blockers | 0.109 | 0.014–0.821 | 0.031 |
Prior atrial fibrillation | 0.415 | 0.184–0.940 | 0.035 |
Prior PVI | 0.099 | 0.036–0.266 | <0.001 |
Prior heart surgery | 0.526 | 0.197–1.407 | 0.201 |
Atrial CL [ms] | 1.004 | 0.990–1.018 | 0.591 |
Atrial CL > 245 ms | 1.135 | 0.472–2.728 | 0.778 |
Regression Coefficient | Standard Error | Wald | df | Sig. | Odds Ratio | 95% Confidence Interval | |
---|---|---|---|---|---|---|---|
Male | 1.104 | 0.470 | 5.505 | 1 | 0.019 | 3.016 | 1.199–7.583 |
AAT with beta blockers | −2.102 | 1.037 | 4.109 | 1 | 0.043 | 0.122 | 0.016–0.933 |
Prior PVI | −0.754 | 0.444 | 2.880 | 1 | 0.090 | 0.470 | 0.197–1.124 |
Odds Ratio | 95% Confidence Interval | p-Value | |
---|---|---|---|
Age [years] | 0.954 | 0.918–0.991 | 0.016 |
Age > 75 years | 0.370 | 0.172–0.796 | 0.011 |
Male | 3.356 | 1.399–8.065 | 0.007 |
Body mass index [kg/m2] | 1.003 | 0.937–1.074 | 0.926 |
Arterial hypertension | 0.375 | 0.150–0.940 | 0.036 |
Hyperlipoproteinemia | 0.820 | 0.391–1.720 | 0.599 |
Diabetes mellitus | 0.828 | 0.378–1.815 | 0.638 |
Coronary heart disease | 1.005 | 0.481–2.099 | 0.990 |
CHA2DS2VASc score [points] | 0.758 | 0.604–0.951 | 0.017 |
AAT with beta blockers | 0.433 | 0.080–2.339 | 0.331 |
Prior atrial fibrillation | 0.699 | 0.333–1.469 | 0.345 |
Prior PVI | 0.638 | 0.200–2.038 | 0.449 |
Prior heart surgery | 3.056 | 1.185–7.877 | 0.021 |
Atrial CL [ms] | 1.017 | 1.005–1.029 | 0.004 |
Atrial CL > 245 ms | 4.205 | 1.863–9.489 | <0.001 |
Regression Coefficient | Standard Error | Wald | df | Sig. | Odds Ratio | 95% Confidence Interval | |
---|---|---|---|---|---|---|---|
Age [years] | −0.032 | 0.022 | 2.073 | 1 | 0.150 | 0.969 | 0.927–1.012 |
Male | 0.967 | 0.482 | 4.030 | 1 | 0.045 | 2.631 | 1.023–6.765 |
Arterial hypertension | −0.524 | 0.536 | 0.955 | 1 | 0.328 | 0.592 | 0.207–1.693 |
Prior heart surgery | 0.547 | 0.531 | 1.062 | 1 | 0.303 | 1.728 | 0.610–4.895 |
Atrial CL > 245 ms | 0.902 | 0.428 | 4.451 | 1 | 0.035 | 2.465 | 1.066–5.701 |
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Katov, L.; Reiländer, S.; Schlarb, A.; Diofano, F.; Aktolga, D.; Teumer, Y.; Bothner, C.; Rottbauer, W.; Weinmann-Emhardt, K. Clinical and Electrophysiological Predictors of Isthmus Dependency in Atrial Flutter. Diagnostics 2025, 15, 1095. https://doi.org/10.3390/diagnostics15091095
Katov L, Reiländer S, Schlarb A, Diofano F, Aktolga D, Teumer Y, Bothner C, Rottbauer W, Weinmann-Emhardt K. Clinical and Electrophysiological Predictors of Isthmus Dependency in Atrial Flutter. Diagnostics. 2025; 15(9):1095. https://doi.org/10.3390/diagnostics15091095
Chicago/Turabian StyleKatov, Lyuboslav, Sonja Reiländer, Alyssa Schlarb, Federica Diofano, Deniz Aktolga, Yannick Teumer, Carlo Bothner, Wolfgang Rottbauer, and Karolina Weinmann-Emhardt. 2025. "Clinical and Electrophysiological Predictors of Isthmus Dependency in Atrial Flutter" Diagnostics 15, no. 9: 1095. https://doi.org/10.3390/diagnostics15091095
APA StyleKatov, L., Reiländer, S., Schlarb, A., Diofano, F., Aktolga, D., Teumer, Y., Bothner, C., Rottbauer, W., & Weinmann-Emhardt, K. (2025). Clinical and Electrophysiological Predictors of Isthmus Dependency in Atrial Flutter. Diagnostics, 15(9), 1095. https://doi.org/10.3390/diagnostics15091095