Comparison of Intra Cardiac Echo (ICE) Guided Verses Non- Intra Cardiac Echo Radiofrequency Catheter Ablation of Cavotricuspid Isthmus Dependent Atrial Flutter

ICE Guided Verses Non- Intra Cardiac Echo Radiofrequency


  • Salman Ahmad Department of Cardiac Electrophysiology, Hayatabad Medical Complex, Peshawar, Pakistan
  • Zahoor Ahmad Khan Department of Cardiac Electrophysiology, Hayatabad Medical Complex, Peshawar, Pakistan
  • Ayesha Zahid Department of Cardiac Electrophysiology, Hayatabad Medical Complex, Peshawar, Pakistan
  • Jibran Ikram Department of Cardiac Electrophysiology, Hayatabad Medical Complex, Peshawar, Pakistan
  • Zahid Aslam Awan Department of Cardiac Electrophysiology, Hayatabad Medical Complex, Peshawar, Pakistan



Arterial flutter, ICE-Guided, Non-ICE, Radiofrequency Catheter Ablation


The isthmus-dependent atrial flutter can be effectively treated with Radiofrequency (RF) catheter ablation. Objectives: To compare the ICE guided versus non-ICE radiofrequency catheter ablation of Cavo tricuspid isthmus dependent atrial flutter. Methods: A cross-sectional study was carried out on 40 patient’s atrial flutter data in the Cardiac Electrophysiology Department, Hayatabad medical Complex Peshawar, Pakistan from August 2017 to August 2022. Patients were categorized into two groups: Group-I (ICE-guided RF catheter ablation) and Group-II (non-ICE RF catheter ablation). The standard protocol of ablation was followed using 40-50 watts power at temperature 60oC.  In the case of an irrigated cooled tip catheter, the flow was limited to 30 mL/hour and the power was limited to 30 watts. Results: The overall mean ablation and flouro time was 9.44 ± 6.93 minutes and 20.64 ± 9.77 minutes respectively. The frequency of patients in Group-I and Group-II was 29 (72.5%) and 11 (27.5%) respectively. Out of the total patients, about 8 (20%) patients had shown failed status in terms of procedure success, out of which 5 (62.5%) were from Group-II. Compared to non-ICE guided procedure, the ICE guided procedure had lesser flouro and ablation time with higher rate of success and lower complications and recurrence. Conclusions: The present study observed that intracardiac echocardiography (ICE) can effectively disclose the Cavo tricuspid isthmus and guide ablation anatomy. Additionally, ICE guided radiofrequency catheter ablation had higher success rate, less flouro and ablation time, and lower complications than non-ICE guided radiofrequency catheter ablation.


Khan I, Shah B, Awan ZA. Intracardiac echocardiography: an extraordinary tool to ablate typical atrial flutter. Journal of Postgraduate Medical Institute. 2020 Apr; 34(3): 203-7.

Bun SS, Latcu DG, Marchlinski F, Saoudi N. Atrial flutter: more than just one of a kind. European Heart Journal. 2015 Sep; 36(35): 2356-63. doi: 10.1093/eurheartj/ehv118.

Rubín JM, Calvo D, Pérez D, Fidalgo A, de la Hera JM, Martínez L, et al. Characterization of a stepwise approach in cavotricuspid isthmus ablation for typical atrial flutter: A randomized study comparing three catheters. Pacing and Clinical Electrophysiology. 2017 Oct; 40(10): 1052-8. doi: 10.1111/pace.13170.

Mendenhall GS, Voigt A, Saba S. Insights into atrioventricular nodal function from patients displaying dual conduction properties: interactive and orthogonal pathways. Circulation: Arrhythmia and Electrophysiology. 2013 Apr; 6(2): 364-70. doi: 10.1161/CIRCEP.113.000248.

Huang JJ, Reddy S, Truong TH, Suryanarayana P, Alpert JS. Atrial appendage thrombosis risk is lower for atrial flutter compared with atrial fibrillation. The American Journal of Medicine. 2018 Apr; 131(4): 442-e13. doi: 10.1016/j.amjmed.2017.10.041.

Sundbøll J, Hováth-Puhó E, Adelborg K, Ording A, Schmidt M, Bøtker HE, et al. Risk of arterial and venous thromboembolism in patients with atrial fibrillation or flutter: a nationwide population-based cohort study. International Journal of Cardiology. 2017 Aug; 241: 182-7. doi: 10.1016/j.ijcard.2017.04.081.

Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, et al. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. EP Europace. 2019 Aug; 21(8): 1143-4. doi: 10.1093/europace/euz202.

Enriquez A, Saenz LC, Rosso R, Silvestry FE, Callans D, Marchlinski FE, et al. Use of intracardiac echocardiography in interventional cardiology: working with the anatomy rather than fighting it. Circulation. 2018 May; 137(21): 2278-94. doi: 10.1161/CIRCULATIONAHA.117.031343.

Filgueiras‐Rama D, de Torres‐Alba F, Castrejón‐Castrejón S, Estrada A, Figueroa J, Salvador‐Montañés Ó, et al. Utility of intracardiac echocardiography for catheter ablation of complex cardiac arrhythmias in a medium‐volume training center. Echocardiography. 2015 Apr; 32(4): 660-70. doi: 10.1111/echo.12714.

Peichl P, Wichterle D, Čihák R, Aldhoon B, Kautzner J. Catheter ablation of ventricular tachycardia in the presence of an old endocavitary thrombus guided by intracardiac echocardiography. Pacing and Clinical Electrophysiology. 2016 Jun; 39(6): 581-7. doi: 10.1111/pace.12844.

Wu J, Chen Y, Ji W, Gu B, Shen J, Fu L, et al. Catheter ablation of ventricular tachycardia in the pediatric patients: A single‐center experience. Pacing and Clinical Electrophysiology. 2020 Jan; 43(1): 37-46. doi: 10.1111/pace.13835.

Busch S, Brachmann J, Saleh A, Forkmann M. Conventional mapping and ablation of focal ventricular tachycardias in the healthy heart. Herzschrittmachertherapie & Elektrophysiologie. 2017 May; 28(2): 187-92. doi: 10.1007/s00399-017-0505-3.

Baykaner T, Quadros KK, Thosani A, Yasmeh B, Mitra R, Liu E, et al. Safety and efficacy of zero fluoroscopy transseptal puncture with different approaches. Pacing and Clinical Electrophysiology. 2020 Jan; 43(1): 12-8. doi: 10.1111/pace.13841.

Žižek D, Antolič B, Prolič Kalinšek T, Štublar J, Kajdič N, Jelenc M, et al. Intracardiac echocardiography-guided transseptal puncture for fluoroless catheter ablation of left-sided tachycardias. Journal of Interventional Cardiac Electrophysiology. 2021 Sep; 61: 595-602. doi: 10.1007/s10840-020-00858-z.

Rosu R, Cismaru G, Muresan L, Puiu M, Gusetu G, Istratoaie S, et al. Intracardiac echocardiography for transseptal puncture. A guide for cardiac electrophysiologists. Medical Ultrasonography. 2019 May; 21(2): 183-90. doi: 10.11152/mu-1827.

Salghetti F, Sieira J, Chierchia GB, Curnis A, de Asmundis C. Recognizing and reacting to complications of trans-septal puncture. Expert review of Cardiovascular Therapy. 2017 Dec; 15(12): 905-12. doi: 10.1080/14779072.2017.1408411.

Yamada T. Idiopathic ventricular arrhythmias: relevance to the anatomy, diagnosis and treatment. Journal of Cardiology. 2016 Dec; 68(6): 463-71. doi: 10.1016/j.jjcc.2016.06.001.

Liu CF, Cheung JW, Thomas G, Ip JE, Markowitz SM, Lerman BB. Ubiquitous myocardial extensions into the pulmonary artery demonstrated by integrated intracardiac echocardiography and electroanatomic mapping: changing the paradigm of idiopathic right ventricular outflow tract arrhythmias. Circulation: Arrhythmia and Electrophysiology. 2014 Aug; 7(4): 691-700. doi: 10.1161/CIRCEP.113.001347.

Liang Z, Ren X, Zhang T, Han Z, Dong J, Wang Y. Mapping and ablation of RVOT-type arrhythmias: comparison between the conventional and reversed U curve methods. Journal of Interventional Cardiac Electrophysiology. 2018 Jun; 52: 19-30. doi: 10.1007/s10840-018-0365-8.

Zhang J, Tang C, Zhang Y, Su X. Pulmonary sinus cusp mapping and ablation: a new concept and approach for idiopathic right ventricular outflow tract arrhythmias. Heart Rhythm. 2018 Jan; 15(1): 38-45. doi: 10.1016/j.hrthm.2017.08.007.

Benhayon D, Nof E, Chik WW, Marchlinski F. Catheter ablation in the right ventricular outflow tract associated with occlusion of left anterior descending coronary artery. Journal of Cardiovascular Electrophysiology. 2017 Mar; 28(3): 347-50. doi: 10.1111/jce.13130.

De Sensi F, Addonisio L, Limbruno U. Premature ventricular complexes ablation above the anterior pulmonary cusp with reversed U curve under intracardiac echocardiography guidance. Journal of Interventional Cardiac Electrophysiology. 2020 Jan; 57(1): 105-6. doi: 10.1007/s10840-019-00654-4.

Ho RT. Cross-sectional imaging of the trileaflet pulmonary valve from the right atrial appendage by intracardiac echocardiography. Journal of cardiovascular electrophysiology. 2019 Aug;30(8):1378-9. doi: 10.1111/jce.14021.

Ehdaie A, Liu F, Cingolani E, Wang X, Chugh SS, Shehata M. How to use intracardiac echocardiography to guide catheter ablation of outflow tract ventricular arrhythmias. Heart Rhythm. 2020 Aug; 17(8): 1405-10. doi: 10.1016/j.hrthm.2020.02.037.

LO LW, TAI CT, LIN YJ, CHANG SL, Wongcharoen W, TUAN TC, et al. Characteristics of the cavotricuspid isthmus in predicting recurrent conduction in the long‐term follow‐up. Journal of Cardiovascular Electrophysiology. 2009 Jan; 20(1): 39-43. doi: 10.1111/j.1540-8167.2008.01269.x.

Ventura R, Klemm H, Lutomsky B, Demir C, Rostock T, Weiss C, et al. Pattern of isthmus conduction recovery using open cooled and solid large‐tip catheters for radiofrequency ablation of typical atrial flutter. Journal of Cardiovascular Electrophysiology. 2004 Oct; 15(10): 1126-30. doi: 10.1046/j.1540-8167.2004.04125.x

Karlsson LO, Jönsson A, Liuba I. Catheter ablation of ventricular tachycardia in a patient with a left endoventricular patch: a case report. European Heart Journal-Case Reports. 2017 Dec; 1(2): ytx016. doi: 10.1093/ehjcr/ytx016.



DOI: 10.54393/pjhs.v4i04.701
Published: 2023-04-30

How to Cite

Ahmad, S. ., Ahmad Khan, Z. ., Zahid, A. ., Ikram, J. ., & Aslam Awan, Z. . (2023). Comparison of Intra Cardiac Echo (ICE) Guided Verses Non- Intra Cardiac Echo Radiofrequency Catheter Ablation of Cavotricuspid Isthmus Dependent Atrial Flutter : ICE Guided Verses Non- Intra Cardiac Echo Radiofrequency. Pakistan Journal of Health Sciences, 4(04), 67–70.



Original Article