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CLINICAL STATEMENTS AND GUIDELINES January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e58 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation a history of AF before ablation than those without AF before ablation (53% versus 23% after 16-18 months; P<0.05).5 The incidence of AF continues to increase over time in both patients with and without previous AF.5 Oral anticoagulation reduces risk of stroke or systemic thromboembolism in the setting of nonvalvular AF.6 Because AF is not necessarily reduced after ablation of AFL, continued anticoagulation is recommended based on thromboembolic risk assessment.The acute success rate for catheter ablation typical AFL is reported to be 92% with a single procedure and 97% with multiple procedures in a meta-analysis.18 However, the subsequent incidence of AF occurring after ablation of CTI-dependent AFL is reported to be 16% to 82%,5,10,11 with a higher incidence in patients with a history of AF before ablation than those without (53% versus 23% after 16-18 months; P<0.05).5 In 1 study, 82% of patients who underwent typical AFL ablation experienced new-onset AF during long-term follow-up (mean, 39 months).11 4 Because of the high rate of occurrence of new- onset AF after CTI ablation, close follow-up and monitoring are recommended. In patients undergoing AFL ablation, the detection of AF in patients without previous AF significantly increased with more frequent monitoring and/or longer duration of follow-up.7 This is especially important in patients at high risk of stroke or thromboembolism (>2%/ year). Intermittent monitoring may be performed with ambulatory monitors or wearable devices. Alternatively, implantable devices can provide more prolonged and continuous monitoring. Implantable cardiac monitors have been used in multiple settings to detect AF, including after AF ablation or in patients with cryptogenic stroke. Implantable cardiac monitors have also been used for surveillance after AF ablation.9 5 Factors that predict AF after flutter ablation include LA enlargement,19–21 inducible AF at the time of flutter ablation,22,23 interatrial conduction time,24 prolonged HV interval,25 COPD,26 obstructive sleep apnea,20 and HATCH (hypertension, age ≥75 years, TIA or stroke, COPD, heart failure) score.21 One study that reported new-onset AF in 38% of patients after AFL ablation demonstrated a thromboembolic event rate of 10% during a mean follow-up of 5 years.12 In a Danish registry of patients undergoing flutter ablation, 5% of patients suffered a stroke, and 10% died during a mean follow-up of 4 years.13 Thus, patients who undergo successful flut- ter ablation are not free from thromboembolic Figure 16. Anticoagulation for Typical (CTI-Dependent) AFL *Intraprocedural documentation of bidirectional block. †For example, left atrial enlargement, inducible AF, COPD, concomitant heart failure. Colors correspond to Table 2. AF indicates atrial fibrillation; AFL, atrial flutter; COPD, chronic obstructive pulmonary disease; and CTI, cavotricuspid isthmus. Downloaded from http://ahajournals.org by on October 7, 2026