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Article

Comparative Efficacy of Cavotricuspid Isthmus Ablation in Sinus Rhythm Versus Typical Atrial Flutter

by
Lyuboslav Katov
,
Yannick Teumer
,
Alyssa Schlarb
,
Sonja Reiländer
,
Deniz Aktolga
,
Federica Diofano
,
Carlo Bothner
,
Wolfgang Rottbauer
and
Karolina Weinmann-Emhardt
*
Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany
*
Author to whom correspondence should be addressed.
Hearts 2024, 5(4), 482-490; https://doi.org/10.3390/hearts5040035
Submission received: 18 September 2024 / Revised: 24 October 2024 / Accepted: 25 October 2024 / Published: 27 October 2024
Browse Figures
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Abstract

:
Background: Cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) is the most common atrial macro-reentrant tachycardia, characterized by a typical ECG pattern (type I ECG). Often, tachycardia terminates before it can be confirmed by an electrophysiological study (EPS), necessitating CTI ablation in sinus rhythm (SR). This study aims to compare the success rate of CTI ablation in patients with type I ECG during SR versus ongoing CTI-dependent AFL, focusing on arrhythmia recurrence. Methods: We screened patients at Ulm University Heart Center from January 2010 to November 2020 with type I ECG who underwent CTI ablation. Patients were divided into two groups: those whose tachycardia terminated before EPS and underwent ablation in SR, and those with ongoing CTI-dependent AFL during EPS. CTI ablation was deemed complete when a bidirectional conductance block was achieved, confirmed after 30 min. Results: A total of 230 patients were included, all showing typical AFL in ECG recordings. Of these, 67 patients underwent ablation in SR, while 163 were ablated during ongoing AFL. The median follow-up time was 2.7 years. Recurrence of CTI-dependent AFL occurred in 8.3% of patients: 4.5% in the SR ablation group and 9.8% in the ongoing AFL group. Kaplan–Meier estimation showed similar efficacy for both methods regarding arrhythmia recurrence (log-rank p = 0.07). Conclusions: Our decade-long study indicates that CTI ablation during SR is as effective as ablation during ongoing CTI-dependent AFL in achieving long-term freedom from arrhythmia. This research supports the efficacy of both techniques in clinical settings, validating a widely practiced approach.

Graphical Abstract

1. Introduction

The most common form of atrial macro-reentrant tachycardia is known as typical ca-votricuspid isthmus (CTI)-dependent atrial flutter (AFL). The overall worldwide incidence of AFL has been reported as 88 cases per 100,000 person-years [1]. The localization of CTI-dependent AFL is in the right atrium (RA), characterized by a macro-reentrant circuit around the tricuspid valve (TV). The anatomical boundaries include the zone of slow conduction, the CTI, the crista terminalis, and the eustachian valve [2,3,4,5]. The cycle length is usually between 200 and 260 ms [6]. Typical electrocardiogram (ECG) findings for CTI-dependent AFL include negative flutter waves with a sawtooth pattern present in electrocardiographic leads II, III, and aVF, as well as positive p-waves in V1 (counterclockwise, type I ECG) [7]. A reverse typical, CTI-dependent AFL is observed much less frequently. Here, the p-waves exhibit a positive deflection in the inferior leads II, III, and aVF, and a negative deflection in lead V1 (clockwise, type II ECG) [8].
Typical AFL can be highly symptomatic and carries a significantly elevated risk (50%) of new-onset atrial fibrillation (AF), increasing vulnerability to stroke and heart failure [8,9,10,11,12]. Thus, screening for AF is advised for patients with a pre-existing history of AFL [13]. The primary treatment choice for CTI-dependent AFL episodes is catheter ablation (CA), due to its higher effectiveness compared to medication and its ability to prevent drug-induced 1:1 atrioventricular conduction, which carries a risk of provoking ventricular fibrillation [14,15]. Moreover, CA demonstrates superior effects on improving quality of life, encompassed by a reduction in AF occurrences and the need for re-hospitalization [16]. The aim of CA is to interrupt the macro-reentry circle. The most straightforward and safe method is CTI ablation, consisting of creating an ablation line along the CTI, starting from the TV to the inferior vena cava (IVC) [5].
Sometimes, a typical AFL ECG pattern (type I ECG) is documented, and the tachycardia ends before CTI-dependent AFL can be confirmed by an electrophysiological study (EPS). CTI ablation is then performed during sinus rhythm (SR). The aim of our study is to evaluate the success rate of CTI ablation in patients with documented type I ECG but ablation in SR, compared to patients with intracardially confirmed CTI-dependent AFL and ablation, in terms of arrhythmia recurrence.

2. Materials and Methods

2.1. Study Population

This retrospective, monocentric follow-up study was conducted from January 2010 to November 2020 at Ulm University Heart Center. We enrolled a total of 230 patients, divided into two groups. In the first group, 67 patients were ablated in SR following spontaneous conversion from typical AFL, as documented by a type I ECG prior to the EPS. In the second group, 163 patients, all with recorded type I ECG, underwent ablation during ongoing CTI-dependent AFL. The inclusion criteria required documentation of typical AFL confirmed by a type I ECG in a 12-lead ECG recording, followed by CTI ablation. All patients under the age of 18 and those with type II ECG or other arrhythmias, such as atypical AFL or AF, were excluded. Prior to the intervention, each patient provided written informed consent. Approval for this study was obtained from the Ethics Committee of Ulm University, and it adheres to the principles outlined in the Declaration of Helsinki.

2.2. Periprocedural Management and Access Route

The procedure was conducted under local anesthesia at the groin site and mild sedation with midazolam boluses, supplemented with propofol if required. The intervention was performed with uninterrupted oral anticoagulation for three weeks; otherwise, left atrial thrombus was ruled out by transesophageal echocardiography examination. A bolus of 5000 IU heparin and fentanyl was administered prior to ablation.
Access to the RA was achieved through the right groin and IVC. Routinely, a double puncture of the right femoral vein was utilized. The coronary sinus (CS) catheter (Inquiry™ Steerable Diagnostic Catheter, Abbott, NC, USA) and the ablation catheter (noncooled BlazerTM 8mm ablation catheter, Boston Scientific, Marlborough, MA, USA, and cooled Thermocool SmarttouchTM ablation catheter, Biosense Webster, Irvine, CA, USA) were introduced via 7 and 8 French sheaths, respectively. The CS catheter was positioned in the CS, both for recording intracardiac electrical signals, as well as for performing intraprocedural stimulation maneuvers.

2.3. Ablation Protocol

At the beginning of the examination, the rhythm of the 12-lead ECG was confirmed by intracardiac signals. If the patient was in SR, conduction times at the CTI were determined before ablation. Therefore, the ablation catheter was positioned in the low RA (LRA), middle RA (MRA), and high RA (HRA). At each location, stimulation maneuvers were performed from the proximal CS catheter electrodes and the distal ablation catheter electrodes, and vice versa. The conduction times between the two catheters were measured in both directions, respectively. If there was no intra-atrial block, the conduction times in SR increased progressively from the LRA to the MRA and further to the HRA. If the patient exhibited ongoing AFL, EPS was conducted to confirm CTI-dependent AFL. Therefore, entrainment was conducted from both the proximal and the distal CS catheter electrodes, as well as from the CTI, and the post-pacing intervals (PPI) were documented. For entrainment, stimulation was performed with a cycle length slightly shorter than the cycle length of the tachycardia. During stimulation, special attention was given to the CS catheter pattern. If the origin of the AFL is in the RA, a concealed CS pattern is expected when stimulating from the proximal electrode of the CS catheter. Following pacing, the time from the last stimulated signal to the first signal of the ongoing tachycardia is evaluated. If the origin of the tachycardia is in the RA, the PPI from the proximal CS catheter electrode is shorter and closer to the cycle length of the AFL compared to the distal CS electrode. Conduction times that were obtained in the EPS were documented in a standardized protocol.
The ablation procedure commenced at the ventricular aspect of the TV annulus, where a distinct atrial potential was observed on the electrode of the ablation catheter. The ablation line was then extended through the CTI and continued until reaching the IVC junction. The ablation was performed continuously by dragging the ablation catheter slowly along the CTI. Atrial signals were carefully monitored to ensure they either vanished entirely during ablation or were markedly attenuated along the ablation line. The procedure was concluded once atrial signals were no longer detectable. According to our protocol, the ablation parameters for noncooled CA were set as an ablation time of 120 s, a maximum of 70 wattage, and a maximum temperature of 60 °C. For cooled point-by-point CA, the maximum power was set to 35 watts with an ablation time of 60 s.
After completing the ablation line, we performed repeat stimulation in SR from LRA, MRA, and HRA, using the distal electrodes of the ablation catheter and the proximal CS electrodes, and vice versa. Bidirectional block was an indicator of successful ablation, defined by the time interval between the CS proximal electrodes and LRA exceeding 150 ms in both directions, or when the initially measured time doubled in both directions. Additionally, the duration from the proximal CS to LRA, MRA, and HRA should have decreased continuously. If these criteria were not met, indicating an incomplete block, additional ablations were performed at the CTI. After successful ablation, a waiting period of 30 min was implemented, during which we repeatedly checked for a durable bidirectional block.

2.4. Follow-Up Management

After a successful ablation procedure, patients were discharged the following day. Prior to discharge, a 12-lead ECG was recorded. During the follow-up period, both the primary care physician and the patient were regularly contacted via telephone to check for any arrhythmia recurrences. If any arrhythmia occurred, patients were scheduled for an EPS and ablation.

2.5. Statistical Analysis

Statistical analysis was conducted using SPSS® Statistics (version 29.0.1.0, IBM, Armonk, NY, USA). Categorical variables were evaluated using cross tables and Chi-square test. The Mann–Whitney U test was used to analyze continuous variables. The paired samples were evaluated using the Wilcoxon test. The log-rank test was conducted to assess survival during the follow-up period. The variables were presented using the median and interquartile range (IQR). Statistical significance was defined as a p-value below 0.05.

3. Results

3.1. Baseline Characteristics

A total of 230 patients were included, of which 192 (83.5%) of the cohort were male. 67 patients were ablated in SR after spontaneous conversion prior to the EPS, while another 163 patients were ablated during ongoing CTI-dependent AFL. The median age of the total cohort was 68 (60.0; 74.2) years, and the median body mass index (BMI) was 26.8 (24.8; 29.7). Diabetes mellitus was present in 43 patients, with a significantly higher proportion (22.2%) in the group with patients ablated during ongoing CTI-dependent AFL (p = 0.04). AF was previously known in 75 patients (33%). Detailed baseline characteristics are presented in Table 1.

3.2. Procedural Characteristics

The median procedure duration for all patients was 82.0 (60.5; 108.0) minutes, and it was significantly shorter during ongoing CTI-dependent AFL compared to ablation in SR (p = 0.03). The atrial cycle length before ablation in SR was 962.0 (780.0; 1065.0) ms, and under ongoing CTI-dependent AFL was 230.0 (220.0; 260.0) ms. The median number of ablations was 11.0 (6.7; 18.0), the median ablation duration was 12.4 (6.0; 22.1) and the median waiting time after ablation was 30.0 (30.0; 30.0) minutes (Table 2).
The duration time between LRA and ostial electrodes of the CS catheter (CSO) before the ablation was 84.5 (60.0; 100.0) ms, and vice versa 70.0 (60.0; 90.0) ms. After ablation, a statistically significant alteration in both LRA-CSO (150.0 (135.0; 160.0) ms) and CSO-LRA (150.0 (130.0; 165.0) ms) duration indicative of bidirectional block was documented (p < 0.001). The detailed presentation of all conduction duration times for each group is shown in Table 3.
During the periinterventional period, no cerebrovascular events, such as strokes or transient ischemic attacks, were observed in either of the two groups.

3.3. Follow-Up

The median follow-up time was 983.5 (321.5; 2241.7) days (2.7 (0.9; 6.1) years). Patients who underwent CTI-ablation during ongoing tachycardia achieved a 90.2% freedom from CTI-dependent AFL. Those treated in SR with documented type I ECG demonstrated a higher freedom from CTI-dependent AFL recurrence rate of 95.5% (log-rank p = 0.07). For the total cohort, the recurrence-free survival rate from CTI-dependent AFL was 91.7% (Figure 1). The difference in recurrence rates was significant when subdividing the groups based on the use of irrigated and non-irrigated ablation catheters (log-rank p = 0.01). During ablation in SR with an irrigated catheter, no recurrences were observed. However, in ablation performed during ongoing AFL, the use of an irrigated catheter was associated with the highest recurrence rates. Supplemental Figure S1 presents the Kaplan–Meier estimation, further stratified by ablation performed in SR versus ongoing AFL, as well as by the use of irrigated versus non-irrigated catheters.

4. Discussion

CTI-dependent AFL is associated with high mortality rates, primarily due to the increased risk of stroke and its association with other heart diseases [5,17]. Furthermore, a history of AFL increases the likelihood of developing AF by 50% [18]. As mentioned in the 2019 guidelines for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC), CA is recommended for symptomatic, recurrent episodes (Class I) and should be considered for first episodes of CTI-dependent AFL (Class IIa) [14]. Furthermore, CA is the most effective therapy to ensure the maintenance of SR and has advantages over pharmacological therapy [14,16,19]. Therefore, one of the most commonly performed procedures in electrophysiology is CTI ablation [20].
To our knowledge, there is currently no direct evidence comparing the ablation of CTI-dependent AFL during ongoing tachycardia versus during SR in patients with documented Type I AFL ECG. The purpose of this decade-long study is to compare these two treatment approaches in terms of long-term efficacy.
In our retrospective, monocentric study conducted over a decade, we analyzed patients with a median follow-up of approximately three years. The median age of the entire cohort was around 70 years, and they were slightly overweight, with a median BMI of about 27. The baseline characteristics were comparable to the data reported by Rahman et al. in their study on AFL [17]. The procedure duration for patients ablated in SR was approximately 10 min longer compared to those undergoing ablation during ongoing CTI-dependent AFL. A possible explanation for this is the extended evaluation of conduction times in the RA during SR as part of a comprehensive EPS before ablation. In the cohort undergoing ablation during ongoing CTI-dependent AFL, only entrainment maneuvers were conducted prior to ablation to confirm the origin of the tachycardia. Moreover, although the number of ablations was the same in both groups, there was a numerical difference in the actual ablation duration. In the AFL group, the ablation duration was shorter. While this difference was not statistically significant, it could potentially contribute to the shorter procedure time observed during AFL ablation. This may be explained by the fact that once the tachycardia was terminated during ablation and bidirectional conduction block was confirmed through stimulation maneuvers, the ablation line was not rechecked based on signals. While this approach is widely accepted, it may not always detect slow conduction gaps that could lead to arrhythmia recurrence. This limitation appears to be even more pronounced when using an irrigated ablation catheter during ablation of ongoing AFL. It is possible that the ablation line near the edges, such as the TV or IVC, might not have been fully completed, which could also account for the slightly higher recurrence rates observed in the AFL group. After successful ablation, there was almost a doubling of the conduction times between CSO and LRA in both directions, indicative of bidirectional conduction block at the CTI. As recommended by Marchandise et al., a waiting period of 30 min was implemented to prevent early recurrences [21]. The global success rate after a CTI-dependent AFL ablation, as shown in the meta-analysis by Spector et al., is 91.7% (88.40–94.93%) after a single ablation procedure [22]. In our study, 90.2% of all patients demonstrated freedom from CTI-dependent AFL recurrence after the follow-up period of three years. The success rate was approximately 4% higher in the group ablated during SR compared to the groups of patients ablated during ongoing and proven CTI-dependent AFL (p = 0.07). We hypothesize that this difference may be due to better signal evaluation during SR compared to ablation during ongoing AFL while creating the initial ablation line. Atrial signals are more pronounced during SR compared to CTI-dependent AFL. In AFL, the flutter waves are typically smaller due to the higher atrial frequency, and the detection of atrial signals during ablation can be more challenging. During ongoing typical flutter, bidirectional conduction block is tested for the first time after termination of the tachycardia. If no conduction block is present, the line is then re-evaluated for remaining signals. If a bidirectional block is present, the ablation was successful. In this case, we did not check the line again for remaining signals. Following ablation, the target cells can also be stunned and edematous, rather than completely destroyed. This affects their conduction abilities, but the cells may potentially recover over time [23]. Ablation in SR directly addresses the disappearance of the signals before moving the catheter to the next position. Thus, we believe that the ablation line can be created more precisely in SR, as opposed to ablation during AFL. This might be another explanation for the slightly higher recurrence rate of patients ablated during ongoing AFL.
Using a 3D electroanatomical mapping system allows for real-time visualization of the ablation line, helping to detect conduction gaps that might be missed with pacing maneuvers alone. Incorporating 3D mapping might help ensure a complete ablation and potentially reduce recurrence rates by providing a more thorough assessment of ablation line continuity.
Another theoretical advantage of performing ablation in patients with SR is the potentially lower risk of stroke, particularly because there is no conversion of the AFL into SR during ablation. In our study, no cardioembolic events were observed in either group. However, larger studies are necessary to comprehensively assess the incidence of stroke following ablation procedures across various patient cohorts.

5. Conclusions

Our decade-long study comparing conventional CTI ablation during ongoing and confirmed tachycardia versus ablation during SR with ECG recordings of typical AFL (type I ECG) suggests that both approaches are equally effective in achieving long-term freedom from CTI-dependent AFL. This study adds evidence to a standard approach that has been globally performed for decades without substantial evidence, reinforcing the efficacy of both methods in clinical practice.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/hearts5040035/s1, Figure S1: Kaplan–Meier estimation of freedom from CTI-dependent AFL recurrence for patients undergoing ablation in SR or during ongoing AFL, using either an irrigated or non-irrigated catheter.

Author Contributions

Conceptualization, L.K. and K.W.-E.; methodology, L.K. and K.W.-E.; software, A.S., S.R., L.K. and K.W.-E.; validation, L.K., K.W.-E. and W.R.; formal analysis, F.D., L.K., Y.T., S.R. and A.S.; investigation, A.S. and S.R.; resources, W.R. and K.W.-E.; data curation, D.A., A.S. and S.R.; writing—original draft preparation, L.K. and K.W.-E.; writing—review and editing, K.W.-E., F.D., C.B. and W.R.; visualization, L.K. and D.A.; supervision, W.R. and K.W.-E.; project administration, L.K. and K.W.-E. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Ulm University (protocol code 324/16 and 12 October 2016).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are available on request from the corresponding author. The data is not publicly available due to data privacy law.

Conflicts of Interest

The authors declare no conflicts of interest.

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Hearts 05 00035 g001
Figure 1. Kaplan–Meier estimation of freedom from CTI-dependent flutter recurrence for patients ablated in sinus rhythm and during CTI-dependent atrial flutter. The patients depicted in red underwent ablation in SR, while those shown in blue underwent ablation during ongoing CTI-dependent AFL. AFL, atrial flutter; CTI, cavotricuspid isthmus; SR, sinus rhythm.
Figure 1. Kaplan–Meier estimation of freedom from CTI-dependent flutter recurrence for patients ablated in sinus rhythm and during CTI-dependent atrial flutter. The patients depicted in red underwent ablation in SR, while those shown in blue underwent ablation during ongoing CTI-dependent AFL. AFL, atrial flutter; CTI, cavotricuspid isthmus; SR, sinus rhythm.
Hearts 05 00035 g001
Table 1. Baseline characteristics of the patients ablated in SR and during ongoing CTI-dependent AFL.
Table 1. Baseline characteristics of the patients ablated in SR and during ongoing CTI-dependent AFL.
Baseline CharacteristicsAll Patients
(n = 230)		Sinus Rhythm
(n = 67)		Typical Atrial Flutter
(Typ I ECG)
(n = 163)		p-Value
Age [years], median (IQR)68 (60.0; 74.2)70 (62.0; 75.0)68 (59.0; 74.0)0.35
Male, n (%)192 (83.5)50 (74.6)142 (87.1)0.02
BMI [kg/m2], median (IQR)26.8 (24.8; 29.7)27.2 (24.7; 29.2)26.7 (24.8; 30.0)0.86
Hypertension, n (%)155 (67.4)42 (62.7)113 (69.3)0.33
Diabetes mellitus, n (%)43 (18.8)7 (10.4)36 (22.2)0.04
Hyperlipoproteinemia, n (%)119 (51.7)32 (47.8)87 (53.4)0.44
Coronary artery disease, n (%)89 (38.4)21 (31.3)68 (41.4)0.17
Prior stroke/TIA, n (%)18 (7.9)5 (7.6)13 (8.0)0.92
Atrial fibrillation, n (%)75 (33)21 (31.3)54 (33.8)0.72
CHA2DS2-VASc score, median (IQR)2.5 (1.0; 4.0) 2.0 (1.0; 4.0)3.0 (1.0; 4.0)0.27
AFL, atrial flutter; BMI, body mass index; CTI, cavotricuspid isthmus; IQR, interquartile range; SR, sinus rhythm; TIA, transient ischemic attack.
Table 2. Procedural characteristics of the patients ablated in SR and during ongoing CTI-dependent AFL.
Table 2. Procedural characteristics of the patients ablated in SR and during ongoing CTI-dependent AFL.
Procedural CharacteristicsAll Patients
(n = 230)		Sinus Rhythm
(n = 67)		Typical Atrial Flutter (Typ I ECG)
(n = 163)		p-Value
Procedure duration [minutes], median (IQR)82.0 (60.5; 108.0)87.5 (68.7; 125.5)78.0 (59.9; 101.0)0.03
Waiting time,
[minutes], median (IQR)		30.0 (30.0; 30.0)30.0 (30.0; 30.0)30.0 (30.0; 30.0)0.82
Number of ablations
[n], median (IQR)		11.0 (6.7; 18.0)11.0 (6.5; 21.0)11.0 (6.5; 16.0)0.80
Ablation duration [minutes], median (IQR)12.4 (6.0; 22.1)17.0 (4.9; 29.4)11.7 (6.1; 20.8)0.33
Atrial cycle length
[ms],
median (IQR)		N/A962.0 (780.0; 1065.0) *230.0 (220.0; 260.0) **N/A
Irrigated ablation
catheter, n (%)		20.0 (8.6)6.0 (9.0)14.0 (8.6)0.96
Non-irrigated ablation catheter, n (%)210 (91.3)61.0 (91.0)149.0 (91.4)
AFL, atrial flutter; CTI, cavotricuspid isthmus; IQR, interquartile range; N/A, not applicable; SR, sinus rhythm. * In sinus rhythm. ** During ongoing CTI-dependent AFL.
Table 3. Duration time between LRA and CSO, and vice versa, in both groups before and after ablation.
Table 3. Duration time between LRA and CSO, and vice versa, in both groups before and after ablation.
LRA-CSO
Duration Time
Before Ablation
[ms],
Median (IQR)		LRA-CSO
Duration Time
After Ablation
[ms],
Median (IQR)		p-Value
LRA-CSO		CSO-LRA
Duration Time
Before Ablation
[ms],
Median (IQR)		CSO-LRA Duration Time After Ablation
[ms],
Median (IQR)		p-Value
CSO-LRA
All patients
(n = 230)		84.0
(60.0; 100.0)		150.0
(135.0; 160.0)		<0.00170.0
(60.0; 90.0)		150.0
(130.0; 165.0)		<0.001
Sinus rhythm
(n = 67)		80.0
(51.2; 100.0)		140.0
(125.0; 157.5)		<0.00170.0
(60.0; 90.0)		140.0
(125.0; 155.0)		<0.001
Typical atrial flutter
(Typ I ECG)
(n = 163)		90.0
(80.0; 105.0) *		150.0
(136.2; 165.0)		<0.00187.5
(70.0; 100.0) *		150.0
(140.0; 170.0)		<0.001
AFL, atrial flutter; CSO, coronary sinus ostium; CTI, cavotricuspid isthmus; ECG, electrocardiogram; EPS, electrophysiological study; IQR, interquartile range; LRA, low right atrium. * This measurement was performed when the tachycardia was interrupted during the EPS, after confirmation of the CTI-dependent AFL and before the ablation began.
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Katov, L.; Teumer, Y.; Schlarb, A.; Reiländer, S.; Aktolga, D.; Diofano, F.; Bothner, C.; Rottbauer, W.; Weinmann-Emhardt, K. Comparative Efficacy of Cavotricuspid Isthmus Ablation in Sinus Rhythm Versus Typical Atrial Flutter. Hearts 2024, 5, 482-490. https://doi.org/10.3390/hearts5040035

AMA Style

Katov L, Teumer Y, Schlarb A, Reiländer S, Aktolga D, Diofano F, Bothner C, Rottbauer W, Weinmann-Emhardt K. Comparative Efficacy of Cavotricuspid Isthmus Ablation in Sinus Rhythm Versus Typical Atrial Flutter. Hearts. 2024; 5(4):482-490. https://doi.org/10.3390/hearts5040035

Chicago/Turabian Style

Katov, Lyuboslav, Yannick Teumer, Alyssa Schlarb, Sonja Reiländer, Deniz Aktolga, Federica Diofano, Carlo Bothner, Wolfgang Rottbauer, and Karolina Weinmann-Emhardt. 2024. "Comparative Efficacy of Cavotricuspid Isthmus Ablation in Sinus Rhythm Versus Typical Atrial Flutter" Hearts 5, no. 4: 482-490. https://doi.org/10.3390/hearts5040035

APA Style

Katov, L., Teumer, Y., Schlarb, A., Reiländer, S., Aktolga, D., Diofano, F., Bothner, C., Rottbauer, W., & Weinmann-Emhardt, K. (2024). Comparative Efficacy of Cavotricuspid Isthmus Ablation in Sinus Rhythm Versus Typical Atrial Flutter. Hearts, 5(4), 482-490. https://doi.org/10.3390/hearts5040035

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