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cardio.atrial_flutter.cardioversion-failed.v1

Refractory atrial flutter — cardioversion-failed

cardiologyacutechronicadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.atrial_flutter.v1 — refractory phenotype: persistent flutter despite ≥2 DCCV at max 200 J biphasic AND/OR ibutilide + amiodarone failure. Mechanism is fixed substrate (long-standing persistent AFL >1 yr, LA enlargement, prior surgical scar). Three management arms per ACC/AHA 2024 (PMID 38753446): (1) catheter ablation Class I (CTI if typical, 3D mapping if atypical); (2) AVN ablation + permanent pacemaker for symptomatic rate-control failure when ablation contraindicated; (3) rate-control acceptance with AC indefinite. Pre-ablation: TEE within 48 h to exclude LAA thrombus when AC not therapeutic ≥3 wk per ACC/AHA 2024. AC lifelong given refractory substrate per CHA2DS2-VASc; LAA occlusion (Watchman) if HAS-BLED ≥3 + AC contraindicated. LEGACY trial (Pathak JACC 2015 PMID 25770315) — risk-factor modification (alcohol, weight, OSA) reduces recurrence; mandatory adjunct. Manifest pointer reuses cardio.atrial_flutter.v1 manifest. Design-brief pointer reuses parent. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (3)

  • history
    Persistent atrial flutter despite ≥2 DCCV attempts at max 200 J biphasic energy — refractory phenotype
    persistent_aflutter_despite_multiple_dccv
  • history
    Failed chemical CV with ibutilide AND amiodarone load — definitive AAD failure
    pharmacologic_cardioversion_failure
  • history
    Long-standing persistent flutter >1 year + structural LA remodeling — fixed substrate, low CV success expected
    long_standing_persistent_aflutter_>1_yr

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Frailty + ablation candidacy + life expectancy for AVN ablation + pacemaker decision
  • sbprequired
    vital • used at RED_FLAGS
    Hemodynamic stability for ablation pre-op + intraprocedural; SBP <90 with RVR → AVN escalation
  • hrrequired
    vital • used at CONTEXT
    HR target 80–110 in chronic flutter (rate-control acceptance); breakthrough RVR drives ablation expedition
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Confirms flutter morphology (typical vs atypical) — drives CTI ablation vs 3D mapping decision; rules out 1:1 conducted (rare with AAD); QTc baseline pre-AAD
  • tte_la_size_ef_functionrequired
    imaging • used at INITIAL_WORKUP
    LA enlargement >50 mm drives lower ablation success; EF reduced → cautious about non-DHP CCB; valvular HD often coexists
  • tee_within_48h_pre_ablationrequired
    imaging • used at TREATMENT
    EXCLUDE LAA thrombus pre-ablation when not on therapeutic AC ≥3 wk — ACC/AHA 2024 (PMID 38753446); deferred ablation if thrombus present
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    DOAC + AAD dose adjustment; contrast for 3D mapping; pre-ablation safety
  • tsh_lft_pulm_function_pre_amiorequired
    lab • used at INITIAL_WORKUP
    Amiodarone toxicity baseline (TFTs / LFTs / PFTs) — required pre-amiodarone load given likely chronic exposure
  • prior_cv_ablation_attempts_count_and_outcomesrequired
    history • used at CONTEXT
    Defines refractoriness severity; ≥2 failed CV → ablation; ≥2 failed ablations → AVN ablation pathway consideration
  • cha2ds2_vasc_factorsrequired
    history • used at RISK_STRATIFICATION
    AC indication + lifelong duration given chronic substrate
  • bleeding_historyrequired
    history • used at RISK_STRATIFICATION
    HAS-BLED + peri-ablation bleed risk; LAA occlusion candidacy if AC contraindicated
  • symptom_burden_eheart_score_or_aflutter_severity_scalerequired
    history • used at RISK_STRATIFICATION
    Drives ablation aggressiveness — symptomatic refractory → expedited ablation; minimally symptomatic → rate-control acceptance acceptable

12-phase flow (11)

  1. 1FRAME
    Persistent flutter despite ≥2 DCCV attempts at 200 J biphasic AND/OR ibutilide + amiodarone failure → refractory phenotype with fixed substrate. Three management arms: (1) catheter ablation Class I (CTI if typical, 3D mapping if atypical); (2) AVN ablation + pacemaker for symptomatic rate-control failure; (3) rate-control acceptance with indefinite AC — ACC/AHA 2024 (PMID 38753446)
    inputs: ecg_12_lead, prior_cv_ablation_attempts_count_and_outcomes
    advance: Refractory phenotype confirmed
  2. 2ENTRY
    Multiple failed CV attempts (electrical or pharmacologic), persistent symptoms, or long-standing persistent flutter referral
    inputs: age
    advance: Engine entered
  3. 3CONTEXT
    CV history (number of attempts, energies, AAD trials), LA size + EF, structural HD, prior ablations, current AC, lifestyle (alcohol, weight, OSA — LEGACY PMID 25770315), symptom burden
    inputs: hr, cha2ds2_vasc_factors, bleeding_history, prior_cv_ablation_attempts_count_and_outcomes, symptom_burden_eheart_score_or_aflutter_severity_scale
    advance: Context complete
  4. 4RED_FLAGS
    New hemodynamic decompensation with breakthrough RVR (SBP <90, pulmonary edema, ischemia) → urgent rate control + DCCV attempt + ablation expedition; pre-excited 1:1 conducted flutter (rare with AAD use) → AVOID AVN blockers, IV procainamide or DCCV
    inputs: sbp
    actions: tachycardia
    advance: Stable
  5. 5INITIAL_WORKUP
    ECG, BMP/Mg, TSH, creatinine, CBC, LFTs (amiodarone screen), TTE, BNP — confirm chronic substrate + amiodarone toxicity baseline
    inputs: ecg_12_lead, tsh_lft_pulm_function_pre_amio, creatinine_egfr, tte_la_size_ef_function
    actions: panel.cardiac, panel.thyroid, panel.renal
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    TEE within 48 h pre-ablation if AC not therapeutic ≥3 wk; cardiac CT/MRI for 3D mapping anatomy if atypical; OSA evaluation (modifiable trigger — LEGACY); concomitant AF on monitor → also route cardio.afib.core.v1
    inputs: tee_within_48h_pre_ablation
    actions: afib_new_onset, acs_pathway
    advance: Branch resolved
  7. 7RISK_STRATIFICATION
    CHA2DS2-VASc (lifelong AC); HAS-BLED (peri-ablation bleed + AVN ablation candidacy); symptom burden → drives ablation aggressiveness vs rate-control acceptance
    inputs: cha2ds2_vasc_factors, bleeding_history, symptom_burden_eheart_score_or_aflutter_severity_scale
    advance: Tier documented
  8. 8TREATMENT
    Three arms: (1) CTI ablation Class I if typical (>95% acute success per Calkins 2007 PMID 17572388); (2) 3D electroanatomic mapping ablation if atypical (60–80% success); (3) AVN ablation + permanent pacemaker for symptomatic rate-control failure when ablation contraindicated. Pre-ablation: TEE within 48 h + AC therapeutic ≥3 wk OR TEE-guided strategy. Rate control with BB / non-DHP CCB. Lifestyle modification per LEGACY (PMID 25770315). AC indefinite — ACC/AHA 2024 (PMID 38753446)
    inputs: hr, creatinine_egfr, tee_within_48h_pre_ablation
    advance: Ablation booked OR AVN ablation pathway entered OR rate-control acceptance documented
  9. 9DISPOSITION
    Inpatient observation post-ablation × 24 h (groin hematoma, tamponade); discharge after ablation with post-procedure plan; admit if AVN ablation + pacemaker (pacer-dependent risk)
    advance: Disposition documented
  10. 10MONITORING
    Telemetry × 24 h post-ablation; groin check first 4 h then q4h × 24 h; QTc on AAD; AC adherence; for AVN ablation patients — pacer interrogation + sensing/threshold checks
    inputs: ecg_12_lead
    advance: Monitoring orders documented
  11. 11FOLLOWUP
    EP at 4 weeks post-ablation; cardiology q3–6 mo; AC continuation lifelong; Holter at 3, 6, 12 mo for recurrence; lifestyle (alcohol, weight, OSA); pacer clinic q6m if AVN ablation; surveillance for atrioesophageal fistula warning weeks 2–6 post-LA ablation
    advance: Follow-up booked