{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T01:12:24Z","timestamp":1760058744215,"version":"build-2065373602"},"reference-count":42,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2025,4,25]],"date-time":"2025-04-25T00:00:00Z","timestamp":1745539200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background: Atrial flutter (AFL) is a macro-reentrant tachycardia classified as cavotricuspid isthmus (CTI)-dependent or non-CTI-dependent based on its reliance on the CTI for conduction. CTI dependence can present as type I ECG (sawtooth flutter waves in inferior leads and positive P-waves in V1) or type II ECG (absence of these characteristics). This study aimed to identify clinical and electrophysiological parameters to improve CTI dependence prediction in AFL. Methods: Patients at the Ulm University Heart Center between 2010 and 2019 with AFL undergoing electrophysiological studies and ablation were enrolled. Clinical and electrophysiological parameters such as age, gender, prior comorbidities, interventions, and medication use were analyzed. Results: The study included 383 patients, with 70% presenting with type I ECG AFL. CTI dependence was observed in 242 (90.3%) type I ECG patients and 52 (45.2%) type II ECG patients. CTI-dependent AFL patients were younger and had fewer comorbidities. Predictors for CTI dependence in type I ECG included male gender (p = 0.006), absence of beta-blocker use (p = 0.031), no prior atrial fibrillation (p = 0.035), and no prior pulmonary vein isolation (p &lt; 0.001). In type II ECG, predictors for CTI dependence included younger age (p = 0.016), male gender (p = 0.007), absence of arterial hypertension (p = 0.036), and longer atrial cycle length (p &lt; 0.001). Conclusions: Identifying clinical and electrophysiological parameters enhances the ability to predict CTI dependence in AFL, offering valuable insights for tailored diagnostic and therapeutic approaches. Coupling these parameters with ECG findings holds promise for refining prediction accuracy and optimizing patient care.<\/jats:p>","DOI":"10.3390\/diagnostics15091095","type":"journal-article","created":{"date-parts":[[2025,4,25]],"date-time":"2025-04-25T10:42:09Z","timestamp":1745577729000},"page":"1095","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Clinical and Electrophysiological Predictors of Isthmus Dependency in Atrial Flutter"],"prefix":"10.3390","volume":"15","author":[{"given":"Lyuboslav","family":"Katov","sequence":"first","affiliation":[{"name":"Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-9481-0950","authenticated-orcid":false,"given":"Sonja","family":"Reil\u00e4nder","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alyssa","family":"Schlarb","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Federica","family":"Diofano","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Deniz","family":"Aktolga","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3347-1728","authenticated-orcid":false,"given":"Yannick","family":"Teumer","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carlo","family":"Bothner","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wolfgang","family":"Rottbauer","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5777-2998","authenticated-orcid":false,"given":"Karolina","family":"Weinmann-Emhardt","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,4,25]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2242","DOI":"10.1016\/S0735-1097(00)00982-7","article-title":"Incidence and Predictors of Atrial Flutter in the General Population","volume":"36","author":"Granada","year":"2000","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1007\/s10840-021-00982-4","article-title":"Comparison of In-Hospital Outcomes of Patients Undergoing Catheter Ablation for Typical versus Atypical Atrial Flutter","volume":"63","author":"Ebner","year":"2022","journal-title":"J. Interv. Card. Electrophysiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2356","DOI":"10.1093\/eurheartj\/ehv118","article-title":"Atrial Flutter: More than Just One of a Kind","volume":"36","author":"Bun","year":"2015","journal-title":"Eur. Heart J."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1111\/pace.13862","article-title":"Cavotricuspid Isthmus Is Constantly a Zone of Slow Conduction: Data from Ultra-High-Resolution Mapping","volume":"43","author":"Bun","year":"2020","journal-title":"Pacing Clin. Electrophysiol. PACE"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1839","DOI":"10.1161\/01.CIR.92.7.1839","article-title":"Role of Right Atrial Endocardial Structures as Barriers to Conduction during Human Type I Atrial Flutter. Activation and Entrainment Mapping Guided by Intracardiac Echocardiography","volume":"92","author":"Olgin","year":"1995","journal-title":"Circulation"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1568","DOI":"10.1161\/01.CIR.101.13.1568","article-title":"Global Right Atrial Mapping of Human Atrial Flutter: The Presence of Posteromedial (Sinus Venosa Region) Functional Block and Double Potentials: A Study in Biplane Fluoroscopy and Intracardiac Echocardiography","volume":"101","author":"Friedman","year":"2000","journal-title":"Circulation"},{"key":"ref_7","unstructured":"Doiny, D., and Merino, J.L. (2024, May 09). Atrial Flutter: Common and Main Atypical Forms. Available online: https:\/\/www.escardio.org\/Journals\/E-Journal-of-Cardiology-Practice\/Volume-11\/Atrial-flutter-common-and-main-atypical-forms."},{"key":"ref_8","first-page":"116","article-title":"Flutter and his limits","volume":"63","author":"Puech","year":"1970","journal-title":"Arch. Mal. Coeur Vaiss."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1162","DOI":"10.1053\/euhj.2001.2658","article-title":"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","volume":"22","author":"Saoudi","year":"2001","journal-title":"Eur. Heart J."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"55","DOI":"10.15420\/aer.2017:5:2","article-title":"Atrial Flutter, Typical and Atypical: A Review","volume":"6","author":"Cosio","year":"2017","journal-title":"Arrhythm. Electrophysiol. Rev."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Gu, Z., Jiao, J., Shen, Y., Ding, X., Zhu, C., Li, M., Chen, H., Ju, W., Gu, K., and Yang, G. A Simple Score to Predict New-Onset Atrial Fibrillation After Ablation of Typical Atrial Flutter. Can. J. Cardiol., 2024.","DOI":"10.1101\/2023.05.18.23290204"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"699","DOI":"10.1007\/s10840-022-01119-x","article-title":"Recurrent Atrial Arrhythmia in a Randomised Controlled Trial Comparing Contact Force-Guided and Contact Force-Blinded Ablation for Typical Atrial Flutter","volume":"63","author":"Kronborg","year":"2022","journal-title":"J. Interv. Card. Electrophysiol."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Li, J.-H., Xie, H.-Y., Chen, Y.-Q., Cao, Z.-J., Tang, Q.-H., Guo, X.-G., Sun, Q., and Ma, J. (2021). Risk of New-Onset Atrial Fibrillation Post-Cavotricuspid Isthmus Ablation in Typical Atrial Flutter Without History of Atrial Fibrillation. Front. Physiol., 12.","DOI":"10.3389\/fphys.2021.763478"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"682","DOI":"10.1016\/j.jacep.2016.03.014","article-title":"Incidence of Atrial Fibrillation After Atrial Flutter Ablation","volume":"2","author":"Maskoun","year":"2016","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_15","first-page":"1880","article-title":"Catheter ablation for atrial flutter: A survey by the European Heart Rhythm Association and Canadian Heart Rhythm Society","volume":"18","author":"Glover","year":"2016","journal-title":"EP Eur."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1093\/eurheartj\/ehz467","article-title":"2019 ESC Guidelines for the Management of Patients with Supraventricular tachycardiaThe Task Force for the Management of Patients with Supraventricular Tachycardia of the European Society of Cardiology (ESC): Developed in Collaboration with the Association for European Paediatric and Congenital Cardiology (AEPC)","volume":"41","author":"Brugada","year":"2020","journal-title":"Eur. Heart J."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1519","DOI":"10.1016\/S0735-1097(96)00345-2","article-title":"Conduction Block in the Inferior Vena Caval-Tricuspid Valve Isthmus: Association with Outcome of Radiofrequency Ablation of Type I Atrial Flutter","volume":"28","author":"Schwartzman","year":"1996","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1898","DOI":"10.1016\/S0735-1097(00)00635-5","article-title":"Prospective Randomized Comparison of Antiarrhythmic Therapy versus First-Line Radiofrequency Ablation in Patients with Atrial Flutter","volume":"35","author":"Natale","year":"2000","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1042","DOI":"10.1161\/01.CIR.0000140263.20897.42","article-title":"Lifetime Risk for Development of Atrial Fibrillation","volume":"110","author":"Wang","year":"2004","journal-title":"Circulation"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"3314","DOI":"10.1093\/eurheartj\/ehae176","article-title":"2024 ESC Guidelines for the Management of Atrial Fibrillation Developed in Collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): Developed by the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC), with the Special Contribution of the European Heart Rhythm Association (EHRA) of the ESC. Endorsed by the European Stroke Organisation (ESO)","volume":"45","author":"Rienstra","year":"2024","journal-title":"Eur. Heart J."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1016\/S0022-0736(99)90002-X","article-title":"Electrocardiographic Differentiation of Atrial Flutter from Atrial Fibrillation by Physicians","volume":"32","author":"Knight","year":"1999","journal-title":"J. Electrocardiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1016\/j.hrthm.2015.07.031","article-title":"Atrial Flutter: Clinical Risk Factors and Adverse Outcomes in the Framingham Heart Study","volume":"13","author":"Rahman","year":"2016","journal-title":"Heart Rhythm"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"482","DOI":"10.3390\/hearts5040035","article-title":"Comparative Efficacy of Cavotricuspid Isthmus Ablation in Sinus Rhythm Versus Typical Atrial Flutter","volume":"5","author":"Katov","year":"2024","journal-title":"Hearts"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1007\/s00399-023-00966-z","article-title":"Rechtsatriales isthmusabh\u00e4ngiges Vorhofflattern","volume":"34","author":"Jilek","year":"2023","journal-title":"Herzschrittmachertherapie Elektrophysiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1029","DOI":"10.1016\/j.hrthm.2007.04.002","article-title":"Atrial Fibrillation Is Common after Ablation of Isolated Atrial Flutter during Long-Term Follow-Up","volume":"4","author":"Chinitz","year":"2007","journal-title":"Heart Rhythm"},{"key":"ref_26","first-page":"941","article-title":"Spanish Catheter Ablation Registry. 17th Official Report of the Spanish Society of Cardiology Working Group on Electrophysiology and Arrhythmias (2017)","volume":"71","year":"2018","journal-title":"Rev. Esp. Cardiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1240","DOI":"10.1016\/j.jacep.2017.05.005","article-title":"Catheter Ablation for Cardiac Arrhythmias: Utilization and In-Hospital Complications, 2000 to 2013","volume":"3","author":"Hosseini","year":"2017","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"820","DOI":"10.1093\/eurheartj\/ehy709","article-title":"A Decade of Catheter Ablation of Cardiac Arrhythmias in Sweden: Ablation Practices and Outcomes","volume":"40","author":"Holmqvist","year":"2019","journal-title":"Eur. Heart J."},{"key":"ref_29","first-page":"1071","article-title":"Is Electrocardiography a Reliable Tool for Identifying Patients with Isthmus-Dependent Atrial Flutter?","volume":"11","author":"Barbato","year":"2009","journal-title":"EP Eur."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e93","DOI":"10.1161\/CIR.0000000000001123","article-title":"Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association","volume":"147","author":"Tsao","year":"2023","journal-title":"Circulation"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"a025148","DOI":"10.1101\/cshperspect.a025148","article-title":"The Aging Heart","volume":"5","author":"Chiao","year":"2015","journal-title":"Cold Spring Harb. Perspect. Med."},{"key":"ref_32","first-page":"43","article-title":"Distribution of Mean Cycle Length in Cavo-Tricuspid Isthmus Dependent Atrial Flutter","volume":"61","author":"Simek","year":"2012","journal-title":"Physiol. Res."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1237","DOI":"10.1253\/circj.CJ-17-0242","article-title":"Aging Modulates the Substrate and Triggers Remodeling in Atrial Fibrillation","volume":"82","author":"Lin","year":"2018","journal-title":"Circ. J."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"640","DOI":"10.1016\/j.jacbts.2019.05.005","article-title":"Atrial Myopathy","volume":"4","author":"Shen","year":"2019","journal-title":"JACC Basic Transl. Sci."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1620","DOI":"10.1016\/j.jacep.2024.04.008","article-title":"Impact of Posterior Wall Isolation During AF Ablation on the Incidence of Left Atrial Flutter","volume":"10","author":"Lim","year":"2024","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_36","first-page":"101018","article-title":"Substrate-based ablation of atypical atrial flutter in patients with atrial cardiomyopathy","volume":"40","author":"Pott","year":"2022","journal-title":"Int. J. Cardiol. Heart Vasc."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"104274","DOI":"10.1016\/j.phrs.2019.104274","article-title":"Antiarrhythmic Mechanisms of Beta Blocker Therapy","volume":"146","author":"Grandi","year":"2019","journal-title":"Pharmacol. Res."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"818","DOI":"10.1016\/S0140-6736(16)31258-2","article-title":"Rate Control in Atrial Fibrillation","volume":"388","author":"Rienstra","year":"2016","journal-title":"Lancet"},{"key":"ref_39","first-page":"793","article-title":"Global Burden of Atrial Fibrillation\/Atrial Flutter and Its Attributable Risk Factors from 1990 to 2019","volume":"25","author":"Dong","year":"2023","journal-title":"EP Eur."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1251","DOI":"10.1111\/j.1540-8159.2011.03137.x","article-title":"Predictors of Unusual ECG Characteristics in Cavotricuspid Isthmus-Dependent Atrial Flutter Ablation. Pacing Clin","volume":"34","author":"Hoffmayer","year":"2011","journal-title":"Electrophysiology"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1007\/s10840-012-9705-2","article-title":"Surgical Technique and the Mechanism of Atrial Tachycardia Late after Open Heart Surgery","volume":"35","author":"Pap","year":"2012","journal-title":"J. Interv. Card. Electrophysiol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1038\/jhh.2014.82","article-title":"Hypertension Prevalence, Awareness, Treatment and Control in Germany 1998 and 2008-11","volume":"29","author":"Neuhauser","year":"2015","journal-title":"J. Hum. Hypertens."}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/15\/9\/1095\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:21:48Z","timestamp":1760030508000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/15\/9\/1095"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,4,25]]},"references-count":42,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2025,5]]}},"alternative-id":["diagnostics15091095"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics15091095","relation":{},"ISSN":["2075-4418"],"issn-type":[{"type":"electronic","value":"2075-4418"}],"subject":[],"published":{"date-parts":[[2025,4,25]]}}}