Revisiting an Underrecognized Strategy for Rhythm Management: Hybrid Therapy for Patients who Convert from Atrial Fibrillation to Flutter on Antiarrhythmic Drugs

Atrial fibrillation (AF) is often treated with antiarrhythmic drugs (AADs) or catheter ablation. In a unique subset of patients, AF can convert to atrial flutter (AFL) after the initiation of an AAD. It has previously been shown that, in this subset of patients, cavotricuspid isthmus (CTI) ablation followed by the continuation of the AAD regimen has an unusually high rate of successfully maintaining sinus rhythm. This is an underrecognized approach toward rhythm management in such patients. However, the reason(s) for such a high degree of efficacy with this hybrid therapeutic approach are unclear. We suggest that conversion from AF to AFL selects for a group of patients in whom AF is particularly responsive to the effects of the AAD. Since CTI ablation is essentially curative of AFL, the combination of both techniques results in a high efficacy of sinus rhythm maintenance. Further investigation is required to confirm these hypotheses.