Incremental pacing maneuver for atrial flutter recurrence reduction after ablation: Vallès: Yield of incremental pacing after flutter ablation

•Achievement of complete CTI block reduces typical flutter recurrences after ablation.•Incomplete block may be underdiagnosed, leading to AFL recurrences after ablation.•The incremental pacing (IP) maneuver improves the assessment of complete CTI block.•The addition of the IP maneuver reduces the incidence of long-term AFL recurrences.•IP maneuver needs neither visualization of CTI nor prolongation of procedure times.

BackgroundA < 20 ms increase in the interval between cavo-tricuspid isthmus (CTI) double potentials during incremental pacing (IP) is a highly specific marker differentiating functional from complete CTI block during typical flutter (AFL) ablation. Long-term effects of IP remain unclear. We aimed to assess the impact of IP in reducing AFL recurrences after CTI ablation.MethodsOne hundred and thirty-four patients (age 67 ± 13 years, 78% males) undergoing successful CTI ablation were included and divided into 2 groups: Group 1 (n = 68), in which ablation was performed before the IP maneuver was incorporated, with CTI block confirmed by at least 1 non-local and 1 local electrogram-based previously established criteria; and Group 2 (n = 66), in which IP maneuver was used to confirm complete CTI block.ResultsNo intergroup differences were noted in baseline characteristics, ablation settings and fluoroscopy/radiofrequency times. Long-term AFL recurrences were observed in 14 out of 134 patients (10.4%), and were more common in Group 1 (19%, vs 1.5% among Group 2 patients, p < 0,001). Despite a longer follow-up period among the former group (1603 ± 734 vs. 964 ± 289 days, respectively), the adjusted AFL recurrence rate was still higher among Group 1 patients (4.3%/year vs. 0.6%/year, p < 0,001). Cox-regression analysis confirmed inclusion in Group 1 as the only predictor of AFL recurrences (HR = 8.2, CI 1.04-64.7, p = 0.046).ConclusionsThe addition of the IP maneuver for the diagnosis of complete CTI block reduces AFL long-term recurrences after ablation.