Atrial flutter catheter ablation in adult patients with repaired tetralogy of Fallot: mechanisms and outcomes of percutaneous catheter ablation in a consecutive series

  • Angelo Biviano
  • Hasan Garan
  • Kathleen Hickey
  • William Whang
  • Jose Dizon
  • Marlon Rosenbaum



Prior investigators note successful ablation of both typical cavotricuspid isthmus-dependent and scar-related macroreentrant right atrial flutters (AFL) in adult patients with repaired tetralogy of Fallot (TOF). However, an analysis of the mechanisms (including a description of a uniform approach to diagnose such mechanisms), and clinical outcomes of catheter ablation in a consecutive series of adult patients with AFL late after surgical TOF repair has not been previously reported.


Background clinical data and follow-up were evaluated in a consecutive series of TOF patients evaluated from September 2001 to June 2008.


We report a prevalence of sustained, symptomatic AFL in patients with repaired TOF equal to 20% (28/140 patients), and of recurrent, drug-refractory and/or severely symptomatic AFL to be 11% (16/140 patients). The AFLs manifested variable cycle lengths ranging from 215 to 525 ms. Underlying mechanisms were: (1) cavotricuspid (CTI)-dependent, counterclockwise atrial flutter (n = 8 patients); (2) non-CTI-dependent macroreentrant scar-related AFL (n = 6 patients); and (3) both CTI- and non-CTI-dependent macroreentrant AFL (n = 2 patients). Recurrent arrhythmias occurred in six patients, five of whom were successfully treated with repeat ablation. After a mean follow-up of 23 months, 15 of 16 patients were alive and free of sustained AFL.


AFL late after surgical TOF repair occurs in 20% of such patients. In more than half of these patients, the AFLs are drug-refractory and/or severely symptomatic. Despite the presence of congenital heart disease treated with prior cardiac surgery and AFLs with variable atrial cycle lengths, the CTI-dependent mechanism underlies approximately half of the sustained, symptomatic AFLs.


Catheter ablation Tachyarrhythmias Atrial flutter Tetralogy of Fallot 



Atrial flutter


Right atrium




Cavotricuspid isthmus


Tetralogy of Fallot


Radiofrequency ablation



The authors would like to thank Ms. Cecille Garcia, N.P., for her assistance with data collection and Ms. AnnaMaria Arias for assistance with manuscript preparation.

Funding Sources

Funded in part by a grant from the New York State Empire Clinical Research Investigator Program (Dr. Biviano).


The authors report no conflicts related to this article.


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Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Angelo Biviano
    • 1
    • 2
  • Hasan Garan
    • 1
  • Kathleen Hickey
    • 1
  • William Whang
    • 1
  • Jose Dizon
    • 1
  • Marlon Rosenbaum
    • 1
  1. 1.Department of Medicine, Cardiology DivisionColumbia University College of Physicians and SurgeonsNew YorkUSA
  2. 2.Columbia University Medical CenterNew YorkUSA

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