HATCH score in the prediction of new-onset atrial

brillation after catheter ablation of typical atrial utter

Ke Chen, MD,* Rong Bai, MD, Wenning Deng, MD, Chuanyu Gao, MD,* Jing Zhang, MD,*
Xianqing Wang, MD,* Shunbao Wang, MD,* Haixia Fu, MD,* Yonghui Zhao, MD,*
Jiaying Zhang, MD,* Jianzeng Dong, MD, Changsheng Ma, MD, FHRS
From the *Department of Cardiology, Henan Provincial Peoples Hospital, Zhengzhou University, Henan,
China and Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
BACKGROUND New-onset atrial brillation (AF) is not uncommon
after ablation of typical atrial utter (AFL); however, limited data are
available for a risk prediction model for the future occurrence of AF in
patients with typical AFL undergoing successful catheter ablation.
OBJECTIVE This study aimed to determine whether the HATCH
score (which is based on hypertension, age Z75 years, transient
ischemic attack or stroke, chronic obstructive pulmonary disease,
and heart failure) is useful for risk prediction of subsequent AF after
ablation of typical AFL.
METHODS A total of 216 consecutive patients presenting with
typical AFL and no history of AF who underwent successful catheter
ablation were enrolled in the study. The clinical endpoint was
occurrence of new-onset AF during follow-up after ablation.
RESULTS During a follow-up period of 29.1 18.3 months, 85
patients (39%) experienced at least 1 episode of AF. Multivariate
Cox regression analysis demonstrated that the HATCH score (hazard
ratio 1.784; 95% condence interval 1.3522.324; P o .001) and
left atrial diameter (hazard ratio 1.270; 95% condence interval
1.1151.426; P o .001) were independently associated with new-

Introduction
Catheter ablation of typical atrial utter (AFL) has a high
long-term success rate1;however, the occurrence of newonset atrial brillation (AF) after successful ablation of
typical AFL is common.27 The incidence of postablation
new-onset AF is progressive, with 25% occurring over 1
year, 49% at 2 years, and 68% over 3 years.57 Prediction of
subsequent AF after ablation of typical AFL is clinically
important to optimize the management of AFL in terms of
surveillance, continuous antiarrhythmic drug (AAD) treatment or anticoagulation, or even prophylactic pulmonary
vein isolation (PVI) during typical AFL ablation.

Address reprint requests and correspondence: Dr Jiaying Zhang,

Department of Cardiology, Henan Provincial Peoples Hospital, 7 WeiWu
Road, Jin Shui District, Zhengzhou 450003, Henan, China. E-mail address:
jy_zhang12@126.com.

1547-5271/$-see front matter B 2015 Heart Rhythm Society. All rights reserved.

onset AF after typical AFL ablation. The area under the receiver
operator characteristic curve based on the HATCH score for
prediction of new-onset AF was 0.743. The HATCH score could be
used to stratify the patients into 2 groups with different incidences
of new-onset AF (69% vs 27%, P o .001) at a cutoff value of 2.
CONCLUSIONS The HATCH score is a useful predictor of new-onset
AF after typical AFL ablation.
KEYWORDS Atrial brillation; Atrial utter; Catheter ablation
ABBREVIATIONS AAD antiarrhythmic drug; ACEI angiotensinconverting enzyme inhibitor; AF atrial brillation; AFL atrial
utter; ARB angiotensin II receptor blocker; COPD chronic
obstructive pulmonary disease; CS coronary sinus; CTI
cavotricuspid isthmus; HATCH hypertension, age Z75 years,
transient ischemic attack or stroke, chronic obstructive pulmonary
disease, heart failure; PVI pulmonary vein isolation; ROC
receiver operating characteristic
(Heart Rhythm 2015;12:14831489) I 2015 Heart Rhythm Society.
All rights reserved.

Previous studies have shown that development of AF and

typical AFL may be favored by similar electrophysiologic
triggers and substrate, particularly in the setting of similar
comorbidities with attendant electrical and structural remodeling.1,810 Atrial electrical disorder may still progress to AF
precipitated by comorbidities even after ablation of typical
AFL.1,8 The HATCH score (a score with points awarded for
hypertension [1 point], age Z75 years [1 point], transient
ischemic attack or stroke [2 points], chronic obstructive
pulmonary disease [COPD; 1 point], and heart failure [2
points]) has been established as a risk prediction model for
AF progression.11 The score reects advanced age and
multiple comorbidities that are associated with structural
and electrical remodeling of the atria that forms the substrate
leading to AF progression.11 Likewise, the development of
AF despite elimination of typical AFL could be due to
progression of the disease process precipitated by advanced
age and the comorbidities. Thus, patients with higher
http://dx.doi.org/10.1016/j.hrthm.2015.04.008

1484
HATCH scores might be more likely to develop postablation
AF. This study aimed to investigate whether the HATCH
score would be predictive of new-onset AF after ablation of
typical AFL.

Methods
Study population
A total of 233 consecutive patients with typical AFL
successfully treated with catheter ablation were enrolled in
the study between March 2008 and December 2013. Typical
AFL was diagnosed when the 12-lead electrocardiogram
(ECG) showed readily visible and regular inverted utter
waves in the inferior leads and positive utter waves in lead
V1, with a regular atrial rate between 240 and 340 bpm.12
Exclusion criteria were age o18 years, contraindication to
anticoagulation, prior nonpharmacologic interventions for
AFL, and prior documentation of AF. All available medical
records and ECG documentation were reviewed carefully by
investigators to exclude the presence of prior AF. The
HATCH score was calculated for each patient based on a
point system (2 points for either a history of transient
ischemic attack/stroke or heart failure, respectively; 1 point
each for hypertension, age Z75 years, or COPD).11 The
study was approved by the institutional ethics review
committee, and all patients provided written informed
consent.

Heart Rhythm, Vol 12, No 7, July 2015

of 17 mL/min. Ablation was deemed successful if bidirectional CTI block was still present at least 20 minutes after the
last radiofrequency application. AF induction was then
attempted by atrial burst pacing according to the operators
preference. Sustained AF was dened as an episode of
induced AF that lasted at least 30 seconds. If AF did not
spontaneously convert to sinus rhythm, electrical cardioversion would then be performed. All patients were given
warfarin after the ablation procedure, bridged with lowmolecular-weight heparin.

Follow-up
After catheter ablation, all patients underwent continuous
ECG monitoring for at least 24 hours before hospital
discharge. No AADs were prescribed after ablation, and
warfarin was withdrawn after 3 months if no recurrent AFL
or AF was detected. After the ablation procedure, 12-lead
ECG and 24-hour Holter recordings were performed systematically to monitor rhythm status at 3 and 6 months and every
6 months thereafter. If the patient was symptomatic, new 12lead ECG and 24-hour Holter recordings were obtained.
New-onset AF was dened as symptomatic or asymptomatic
AF documented by 12-lead ECG or 24-hour Holter monitoring that lasted at least 30 seconds.16 The clinical endpoint
was occurrence of new-onset AF during follow-up. The time
from the ablation procedure to occurrence of new-onset AF
was determined.

Electrophysiology study and catheter ablation

Before the procedure, all AADs except amiodarone were
discontinued for at least 5 half-lives. After exclusion of left
atrial thrombus by transesophageal echocardiography, lowmolecular-weight heparin was administered subcutaneously
until the day of the ablation procedure.
All patients underwent cavotricuspid isthmus (CTI)
ablation with the CARTO electroanatomic mapping system
(Biosense Webster, Diamond Bar, CA). The primary goal of
the procedure was to create a line of bidirectional conduction
block in the inferior isthmus between the inferior vena cava
orice and the tricuspid annulus, according to the combined
methods detailed elsewhere.1315 A decapolar steerable
catheter was advanced to the coronary sinus (CS) through
the left femoral vein. For patients in AFL at the onset of the
procedure, CTI dependence of utter was conrmed by
activation mapping and entrainment mapping. CTI ablation
was then performed during utter. AFL was induced by atrial
burst pacing in patients who presented with sinus rhythm at
the time of the procedure. Burst pacing was sequentially
performed at cycle lengths of 600, 500, and 400 ms, then
progressively shortened by 10 ms per burst until 2:1 atrial
capture from the inferolateral tricuspid annulus and then
again from the proximal CS. In patients without inducible
AFL, ablation of the CTI was performed during pacing from
the proximal CS. Irrigated radiofrequency energy was
delivered with a 3.5-mm-tip ablation catheter (NAVISTAR
THERMOCOOL, Biosense Webster) using a target temperature of 431C, a maximal power of 35 W, and an infusion rate

Statistical analysis
All statistical analyses were performed with SPSS 16.0
(IBM, Armonk, NY). Values are presented as mean SD
for normally distributed continuous variables, median (interquartile range) for non-normally distributed continuous
variables, and proportions for categorical variables. Continuous variables were compared by unpaired Student t tests for
normally distributed variables and Mann-Whitney U test for
skewed variables. Categorical variables were compared by
2 or Fisher exact tests. Occurrence rates of new-onset AF
between groups with different HATCH scores were compared by the 2 test for linear trends. Cox proportional
hazards models were used to identify predictors of new-onset
AF. Variables with a P value o.05 found on univariate
analysis were selected to be tested in the multivariate
analysis. The variance ination factor was used to measure
collinearity in a multivariate regression analysis, and any
value larger than 10.0 was considered signicant. The
variables analyzed in the multivariate Cox regression model
were tested with the use of variance ination factors to
minimize the risk of overadjustment. A receiver operating
characteristic (ROC) curve was constructed to test the ability
of the HATCH score to predict new-onset AF and identify
the optimal cutoff value. The predictive accuracy of the
HATCH score was identied by use of the Youden index
(sensitivity specicity  1). Kaplan-Meier analysis with a
log-rank test was performed to determine how different HATCH
scores were related to the cumulative risk of new-onset AF.

Chen et al

HATCH Score Predicts AF After Ablation of AFL

1485

All probability values were 2-sided, and P o .05 was

considered statistically signicant.

bidirectional CTI block during the ablation procedure had

recurrences of typical AFL. Of the 11 patients with recurrence, 7 underwent successful repeat AFL ablation, and 4
patients with episodes of AF received repeat ablation for AF
and AFL. None of the redo patients have had further
recurrences during follow-up.

Results
Clinical characteristics
Of the 233 patients enrolled, 17 were excluded from the
present study, 6 because of a lack of follow-up and the other
11 because of AFL recurrence. A total of 216 patients were
therefore included in this study. Baseline characteristics in
relation to occurrence of new-onset AF are showed in
Table 1. There were no signicant differences in baseline
characteristics between patients who did and those who did
not complete the study.

AFL ablation and recurrence

Bidirectional CTI block was achieved in 226 of 233 patients
(97%) during the ablation procedure. AF induction was
attempted in 56 (25%) of the 226 blocked patients after AFL
ablation, and sustained AF could be induced in 12 patients
(21%). In the remaining 7 unblocked patients (3%), neither
AFL nor AF could be induced at the end of the procedure.
Typical AFL recurred in 11 patients (5%) at a median of 11
months after the index ablation, accompanied by episodes of
AF in 4 of these patients. Of note, all 7 patients without
Table 1

Baseline characteristics

Variables
Age, y
Men
Body mass index, kg/m2
Medical history
Hypertension
Diabetes mellitus
Coronary artery disease
Heart failure
Previous stroke/TIA
Valvular disease
COPD
Obstructive sleep apnea
Echocardiogram characteristics
LAD, mm
LVEF, %
Medication use
AAD use before ablation
Beta-blocker
Calcium channel blocker
ACEI/ARB
Digitalis
Diuretic agents
Statins
HATCH score

No AF
AF (n 85) (n 131) P Value
65.8 11.7 61.7 9.7
64 (75)
104 (79)
26.7 3.5 26.4 3.5
66 (78)
13 (15)
21 (24)
26 (31)
10 (12)
14 (17)
8 (9)
7 (8)
41.5 4.5
51.5 10
20
60
27
35
21
35
30
2

(24)
(71)
(32)
(41)
(25)
(41)
(35)
(1, 2)

78 (60)
23 (18)
29 (22)
15 (12)
5 (4)
9 (7)
6 (5)
10 (8)

.006
.479
.556
.006
.663
.662
o.001
.025
.025
.159
.873

38.5 4.6 o.001

54.9 9
.011
27 (21)
.612
82 (63)
.227
35 (27)
.423
52 (40)
.828
14 (11)
.006
31 (24)
.006
47 (36)
.930
1 (0, 1) o.001

Values are mean SD, n (%), or median (interquartile range).

AADs antiarrhythmic drug; ACEI angiotensin-converting enzyme
inhibitor; AF atrial brillation; ARB angiotensin II receptor blocker;
COPD chronic obstructive pulmonary disease; HATCH score score based
on hypertension, age Z75 years, transient ischemic attack or stroke,
chronic obstructive pulmonary disease, and heart failure; LAD left atrial
diameter; LVEF left ventricular ejection fraction; TIA transient ischemic
attack.

Occurrence and predictors of new-onset AF after AFL

ablation
During the follow-up period of 29.1 18.3 months, 85
patients (39%) experienced at least 1 episode of AF. Of
these, 78 patients (92%) developed paroxysmal AF, with 14
of them (18%) progressing to persistent AF; 7 patients (8%)
developed persistent AF, with 3 of them (43%) progressing
to permanent AF. New-onset AF occurred at a median of 14
months after ablation. Forty patients (47%) experienced AF
within the rst year after ablation, 18 (21%) within the
second year, 15 (18%) within the third year, and 12 (14%)
beyond 3 years, respectively. Notably, a greater incidence of
new-onset AF was observed in patients with inducible
sustained AF than in those without (58% vs 32%, P
.093), yet this did not reach statistical signicance. During
follow-up, AF ablation was performed for highly symptomatic AF in 24 patients (28%); the other 61 patients (72%)
were treated with AADs. Of these, 56 patients (66%) were
treated with long-term anticoagulant therapy.
The HATCH score was an independent predictor of the
occurrence of new-onset AF in the multivariate Cox regression model. The hazard ratio of an increment of the HATCH
scores per point to predict new-onset AF was 1.784 (95%
condence interval 1.3522.324, P o .001). Left atrial
diameter also served as a signicant predictor (Table 2).

HATCH score for prediction of new-onset AF after

AFL ablation
As shown in Figure 1, the incidence of new-onset AF
increased continuously with an increase of the HATCH
score (P o .001). Figure 2 shows the ROC curve for
predicting AF after AFL ablation based on the HATCH
score. The area under the curve for the HATCH score for
predicting AF was 0.743. At a cutoff point of 2 identied by
the ROC curve (sensitivity 51.8%, specicity 84.7%), baseline characteristics of patients with different HATCH scores
are showed in Table 3. Patients with a HATCH score Z2
were more likely to have advanced age, an enlarged left
atrium, and reduced left ventricular ejection fraction and
were more likely to be treated with a beta-blocker, digitalis,
angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB), or diuretic agents than
those with a HATCH score o2. Also, as shown by KaplanMeier survival analysis, a HATCH score Z2 was associated
with a higher incidence of AF than a HATCH score o2
(69% vs 27%, P o .001) during the follow-up period
(Figure 3). Among patients who developed new-onset AF,
those with a HATCH score Z2 had a shorter median time to
develop AF than those with a HATCH score o2 (11 vs 18

1486
Table 2

Heart Rhythm, Vol 12, No 7, July 2015

Cox regression analysis for predictors of new-onset atrial brillation after atrial utter ablation
Univariate analysis

Multivariate analysis

Variables

HR

95% CI

P Value

HR

95% CI

P Value

Age
Hypertension
Heart failure
Stroke/TIA
Valvular disease
LAD
LVEF
HATCH score

1.046
2.521
2.007
2.924
2.505
1.468
0.928
2.027

1.0191.075
1.4724.318
1.7763.819
1.4985.708
1.3984.490
1.2881.673
0.8260.971
1.6592.689

.010
.001
.002
.002
.002
o.001
o.001
o.001

1.270

1.784

1.1151.426

1.3522.324

o.001

o.001

CI condence interval; HR hazard ratio; other abbreviations as in Table 1.

months, P .105), although this did not reach statistical

signicance.

Discussion
To the best of our knowledge, this study is the rst to assess
the ability of a risk-prediction model to predict new-onset AF
after ablation of typical AFL and demonstrated that the
HATCH score is useful for stratifying the risk of postablation
AF in this subset of patients.
As expected, we observed that approximately 40% of the
population experienced at least 1 AF episode within 29.1
18.3 months after AFL ablation. Several factors have been
reported to be associated with future development of AF
after ablation of typical AFL in the past: a history of AF, left
atrial enlargement, reduced left ventricular ejection fraction,
AF inducibility, treatment with AADs before ablation, and
female sex.2,5,1719 However, a predictive model that can
provide an estimate of the risk of postablation AF is lacking.
The HATCH scoring system was originally developed by
de Vos et al according to data from the Euro Heart Survey of
AF.11 The score enables the detection of patients who are at
high risk of progression from paroxysmal AF to more
sustained forms of AF in the near future. Nearly half of
patients with a HATCH score 45 progressed to persistent

Figure 1 Incidence of new-onset atrial brillation and HATCH score

(score based on hypertension, age Z75 years, transient ischemic attack or
stroke, chronic obstructive pulmonary disease, and heart failure).

AF compared with 6% of patients with a HATCH score of 0.

The predictive role of the HATCH score in AF progression
after catheter ablation of paroxysmal AF was investigated in
a study by Jongnarangsin et al,20 which revealed no value of
the score in the prediction of AF progression after ablation;
however, the study population in that study was highly
selected, with a lower mean HATCH score and a narrower
range of HATCH scores than in the study by de Vos et al.11
Recently, Pokushalov et al21 reported that an elevated
HATCH score was an independent strong predictor of AF
burden progression after a failed initial ablation in patients
with paroxysmal AF. The present study demonstrates that the
HATCH score has a satisfying predictive value for newonset AF after ablation of typical AFL, which is a novel
nding.
Comparison of the study population with a HATCH score
Z2 and those with a HATCH score o2 revealed that
patients with higher scores had greater left atrial size, as
shown in Table 3. Furthermore, the relationship between left

Figure 2 Receiver-operator characteristic curve for prediction of atrial

brillation with the HATCH score (score based on hypertension, age Z75
years, transient ischemic attack or stroke, chronic obstructive pulmonary
disease, and heart failure). AUC area under the curve.

Chen et al

HATCH Score Predicts AF After Ablation of AFL

Table 3 Baseline characteristics in patients with different

HATCH scores
Variables
Age, y
Male
Body mass index, kg/m2
Medical history
Hypertension
Diabetes mellitus
Coronary artery disease
Heart failure
Previous stroke/TIA
Valvular disease
COPD
Obstructive sleep apnea
Echocardiogram
characteristics
LAD, mm
LVEF, %
Medication use
AAD use before ablation
Beta-blocker
Calcium channel blocker
Digitalis
ACEI/ARB
Diuretic agents
Statins

HATCH score HATCH score

Z2 (n 64) o2 (n 152) P Value
68.8 7.4
48 (75)
27.0 3.7

61.0 11.1
120 (79)
26.3 3.5

o.001
.524
.211

37 (58)
7 (11)
11 (17)
38 (70)
12 (19)
19 (30)
13 (20)
3 (5)

107 (70)
29 (19)
39 (26)
4 (3)
3 (2)
5 (3)
1 (1)
14 (9)

.073
.143
.178
o.001
o.001
o.001
o.001
.260

44.5 2.5
43.8 4.8

37.7 4.0
57.6 7.9

o.001
o.001

31 (20)
89 (59)
48 (32)
3 (2)
41 (27)
20 (13)
56 (37)

.454
.001
.150
o.001
o.001
o.001
.572

16
53
14
32
46
46
21

(25)
(83)
(22)
(50)
(72)
(72)
(33)

Values are mean SD or n (%). Abbreviations as in Table 1.

atrial enlargement and higher incidence of new-onset AF has

long been recognized in previous studies.22,23 Presumably,
patients with higher HATCH scores represent a population
with an already enlarged and remodeled left atrium, signifying a more advanced disease state that portends the development of clinically relevant AF. This possibility is supported
by the observation that left atrial diameter was also independently associated with postablation AF in the study
population.

Figure 3 Atrial brillationfree survival curves for patients with different

HATCH scores (score based on hypertension, age Z75 years, transient
ischemic attack or stroke, chronic obstructive pulmonary disease, and heart
failure).

1487
In prior studies, a history of AF was the most consistently identied risk factor for subsequent AF after ablation
of typical AFL.2,18,19 However, PVI and CTI ablation are
performed during the same procedure whenever there is
clinical documentation of symptomatic AF and typical AFL
in our center. This strategy was recently demonstrated to be
benecial in terms of AF recurrence and quality of life.8
Therefore, the relationship between a history of AF and
postablation AF could not be assessed systematically in the
present study. Observations by Joza et al17 suggested that
the inducibility of AF after typical AFL ablation was
independently associated with the risk of future AF among
patients with no previous documented episode of AF. In
this study, atrial burst pacing was not routinely performed
at the end of the procedure, which hindered us from
investigating the role of AF inducibility in the development
of postablation AF. With regard to the association of AAD
treatment before ablation and a higher risk of new-onset
AF, Brembilla-Perrot et al2 hypothesized that class I and III
AADs likely masked previous episodes of AF that emerged
after the discontinuation of AADs after ablation. In contrast
to the observations by Brembilla-Perrot et al, we did not
nd that treatment with AADs before AFL ablation was
associated with postablation AF. Also, we did not nd sexrelated differences in postablation AF. The difference in
results could be attributed to disparities in the study
population.
The results of the present study provide evidence for
extending the usefulness of HATCH score to the management of AFL in patients who have received catheter ablation.
First, patients with higher HATCH scores should be advised
of the likelihood of AF occurrence after AFL ablation. More
vigilant surveillance for the detection of AF and a cautious
assessment of the risk-benet ratio regarding discontinuation
pf anticoagulation or antiarrhythmic therapy after ablation
may be required in these patients. Voight et al3 reported that
the presence of a cardiac implantable electronic device
signicantly enhances the likelihood of detecting newonset AF after typical AFL ablation, with AF detected in
48% of those with a cardiac implantable electronic device,
35% with Holter recordings, and 19% with clinical follow-up
only. The implantation of a loop recorder may not be feasible
for all patients who have received catheter ablation of typical
AFL because of the added invasiveness and cost, but this
technique potentially could be applied to those patients at a
signicantly higher risk of developing new-onset AF.
Second, the HATCH score may help to identify whether
patients with typical AFL as the sole atrial arrhythmia need
prophylactic PVI to prevent future occurrence of AF during
ablation of AFL. Recently presented data suggested that in
patients with typical AFL as the only clinical arrhythmia, the
addition of PVI to CTI ablation resulted in a marked
reduction of new-onset AF at 1 year.24 Given the incremental
risk of complications, iatrogenic arrhythmia, and added cost,
prophylactic PVI should be viewed with caution on an
individual basis. The HATCH score may help identify those
patients at higher risk of developing AF in whom the benets

1488
are most likely to outweigh the risks of a second procedure
for AF.
Finally, our ndings argued in favor of the concept that
upstream therapy that targets the comorbidities included in
the HATCH score (hypertension, COPD, and heart failure)
may reduce the incidence of postablation AF. Ann et al25
showed that ACEIs, ARBs, and diuretic agents appear to
have a protective effect against the development of postablation AF. Bazan et al26 reported that treatment of
obstructive sleep apnea, which was regarded as a risk factor
for postablation AF, with continuous positive airway pressure was associated with a lower incidence of new-onset AF
after AFL ablation. Similarly, a recently published study
revealed that aggressive risk factor management improved
the long-term efcacy of AF ablation, which underscores the
importance of therapy directed at the primary promoters of
the underlying atrial substrate to facilitate rhythm control
strategies.27

Heart Rhythm, Vol 12, No 7, July 2015

6.

7.

8.

9.
10.

11.

12.

Study limitations
There are several limitations to this study. First, although
patients medical records and ECG documentation were
carefully reviewed to exclude the presence of AF before
ablation, asymptomatic AF may have been present and
undiagnosed. Similarly, the frequency of postablation AF
may be underestimated in some patients because of asymptomatic AF episodes. Second, the follow-up duration was
relatively short. It is possible that occurrence of postablation
AF would vary over a more prolonged period of follow-up.
Third, this study had a relatively small sample size. The score
must be well validated in further prospective and large-scale
trials before it can be applied in clinical practice. In addition,
there may be a role of periprocedural drug use, such as
ACEIs, ARBs, and diuretic agents, for long-term arrhythmia
prevention. However, the effect of upstream therapy on the
development of new-onset AF is extremely difcult to
evaluate in this study.

13.

14.

15.

16.

Conclusion
The HATCH score proved to be a useful tool in predicting
new-onset AF after successful typical AFL ablation.

17.

18.

References
1. Prez FJ, Schubert CM, Parvez B, Pathak V, Ellenbogen KA, Wood MA. Longterm outcomes after catheter ablation of cavo-tricuspid isthmus dependent atrial
utter: a meta-analysis. Circ Arrhythm Electrophysiol 2009;2:393401.
2. Brembilla-Perrot B, Girerd N, Sellal JM, Olivier A, Manenti V, Villemin T,
Beurrier D, de Chillou C, Louis P, Selton O, de la Chaise AT. Risk of atrial
brillation after atrial utter ablation: impact of AF history, gender, and
antiarrhythmic drug medication. J Cardiovasc Electrophysiol 2014;25:813820.
3. Voight J, Akkaya M, Somasundaram P, Karim R, Valliani S, Kwon Y, Adabag S.
Risk of new-onset atrial brillation and stroke after radiofrequency ablation of
isolated, typical atrial utter. Heart Rhythm 2014;11:18841889.
4. Mittal S, Pokushalov E, Romanov A, Ferrara M, Arshad A, Musat D, Preminger
M, Sichrovsky T, Steinberg JS, Long-term ECG. monitoring using an implantable loop recorder for the detection of atrial brillation after cavotricuspid
isthmus ablation in patients with atrial utter. Heart Rhythm 2013;10:15981604.
5. Ellis K, Wazni O, Marrouche N, et al. Incidence of atrial brillation postcavotricuspid isthmus ablation in patients with typical atrial utter: left-atrial size

19.

20.

21.

22.

as an independent predictor of atrial brillation recurrence. J Cardiovasc

Electrophysiol 2007;18:799802.
Chinitz JS, Gerstenfeld EP, Marchlinski FE, Callans DJ. Atrial brillation is
common after ablation of isolated atrial utter during long-term follow-up. Heart
Rhythm 2007;4:10291033.
Da CA, Thevenin J, Roche F, et al. Results from the Loire-Ardche-Drme-IsrePuy-de-Dme (LADIP) trial on atrial utter, a multicentric prospective randomized study comparing amiodarone and radiofrequency ablation after the rst
episode of symptomatic atrial utter. Circulation 2006;114:16761681.
Mohanty S, Mohanty P, Di Biase L, et al. Results from a single-blind, randomized
study comparing the impact of different ablation approaches on long-term
procedure outcome in coexistent atrial brillation and utter (APPROVAL).
Circulation 2013;127:18531860.
Waldo AL, Feld GK. Inter-relationships of atrial brillation and atrial utter
mechanisms and clinical implications. J Am Coll Cardiol 2008;51:779786.
Morton JB, Byrne MJ, Power JM, Raman J, Kalman JM. Electrical remodeling
of the atrium in an anatomic model of atrial utter: relationship between substrate and triggers for conversion to atrial brillation. Circulation 2002;105:
258264.
de Vos CB, Pisters R, Nieuwlaat R, Prins MH, Tieleman RG, Coelen RJ, van den
Heijkant AC, Allessie MA, Crijns HJ. Progression from paroxysmal to persistent
atrial brillation clinical correlates and prognosis. J Am Coll Cardiol 2010;55:
725731.
January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the
management of patients with atrial brillation: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
and the Heart Rhythm Society [published correction appears in J Am Coll Cardiol
2014;64:23052307]. J Am Coll Cardiol 2014;64:e1e76.
Shah D, Haissaguerre M, Takahashi A, Jas P, Hocini M, Clmenty J. Differential
pacing for distinguishing block from persistent conduction through an ablation
line. Circulation 2000;102:15171522.
Chen J, de Chillou C, Basiouny T, Sadoul N, Filho JD, Magnin-Poull I,
Messier M, Aliot E. Cavotricuspid isthmus mapping to assess bidirectional block
during common atrial utter radiofrequency ablation. Circulation 1999;100:
25072513.
Poty H, Saoudi N, Nair M, Anselme F, Letac B. Radiofrequency catheter ablation
of atrial utter: further insights into the various types of isthmus block:
application to ablation during sinus rhythm. Circulation 1996;94:32043213.
Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert
consensus statement on catheter and surgical ablation of atrial brillation:
recommendations for patient selection, procedural techniques, patient management and follow-up, denitions, endpoints, and research trial design: a report of
the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation
of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm
Association (EHRA), a registered branch of the European Society of Cardiology
(ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart
Association (AHA), the Asia Pacic Heart Rhythm Society (APHRS), and the
Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the
American College of Cardiology Foundation, the American Heart Association,
the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacic Heart Rhythm Society,
and the Heart Rhythm Society. Heart Rhythm 2012;9:632696.
Joza J, Filion KB, Eberg M, Proietti R, Nascimento T, Bernier M, Hadjis T,
Essebag V. Prognostic value of atrial brillation inducibility after right atrial
utter ablation. Heart Rhythm 2014;11:18701876.
Bertaglia E, Zoppo F, Bonso A, Proclemer A, Verlato R, Coro L, Mantovan R,
D'Este D, Zerbo F, Pascotto P; on behalf of the Northeastern Italian Study on
Atrial Flutter Ablation Investigators. Long term follow up of radiofrequency
catheter ablation of atrial utter: clinical course and predictors of atrial brillation
occurrence. Heart 2004;90:5963.
Da CA, Romeyer C, Mourot S, Messier M, Cerisier A, Faure E, Isaaz K. Factors
associated with early atrial brillation after ablation of common atrial utter: a
single centre prospective study. Eur Heart J 2002;23:498506.
Jongnarangsin K, Suwanagool A, Chugh A, Crawford T, Good E, Pelosi F Jr,
Bogun F, Oral H, Morady F. Effect of catheter ablation on progression of
paroxysmal atrial brillation. J Cardiovasc Electrophysiol 2012;23:914.
Pokushalov E, Romanov A, De Melis M, Artyomenko S, Baranova V, Losik D,
Bairamova S, Karaskov A, Mittal S, Steinberg JS. Progression of atrial brillation
after a failed initial ablation procedure in patients with paroxysmal atrial
brillation: a randomized comparison of drug therapy versus reablation. Circ
Arrhythm Electrophysiol 2013;6:754760.
Abhayaratna WP, Seward JB, Appleton CP, Douglas PS, Oh JK, Tajik AJ, Tsang
TS. Left atrial size: physiologic determinants and clinical applications. J Am Coll
Cardiol 2006;47:23572363.

Chen et al

HATCH Score Predicts AF After Ablation of AFL

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23. Vaziri SM, Larson MG, Benjamin EJ, Levy D. Echocardiographic predictors of
nonrheumatic atrial brillation: the Framingham Heart Study. Circulation
1994;89:724730.
24. Steinberg JS, Romanov A, Musat D, Preminger M, Bayramova S, Artyomenko S,
Shabanov V, Losik D, Karaskov A, Shaw RE, Pokushalov E. Prophylactic
pulmonary vein isolation during isthmus ablation for atrial utter: the PReVENT
AF Study I. Heart Rhythm 2014;11:15671572.
25. Ann W, Willems R, Van der Merwe N, Van de Werf F, Ector H, Heidbchel H.
Atrial brillation after radiofrequency ablation of atrial utter: preventive effect

of angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, and

diuretics. Heart 2004;90:10251030.
26. Bazan V, Grau N, Valles E, Felez M, Sanjuas C, Cainzos-Achirica M, Benito B,
Jauregui-Abularach M, Gea J, Bruguera-Cortada J, Marti-Almor J. Obstructive
sleep apnea in patients with typical atrial utter: prevalence and impact on
arrhythmia control outcome. Chest 2013;143:12771283.
27. Pathak RK, Middeldorp ME, Lau DH, et al. Aggressive Risk Factor Reduction
Study for Atrial Fibrillation and implications for the outcome of ablation: the
ARREST-AF Cohort Study. J Am Coll Cardiol 2014;64:22222231.

CLINICAL PERSPECTIVES
Despite the long-term efcacy of CTI ablation, which has been approved for the treatment of typical AFL, a signicant
proportion of patients will develop AF during follow-up; however, a risk-prediction model for new-onset AF after typical
AFL ablation is lacking. The present study demonstrated that the HATCH score can be used to stratify the risk of
postablation AF in this subset of patients. Patients with higher HATCH scores may require more rigorous surveillance for
the detection of AF, as well as more cautious assessment of risk-benet ratios for pursuing anticoagulation or
antiarrhythmic drug therapy after AFL ablation. In addition, upstream therapy that targets the comorbidities included in
the HATCH score may reduce the incidence of postablation AF.