Key result
PVI cuts atrial tachyarrhythmias ~43% versus CTI alone in typical atrial flutter.
Why the study?
Post-ablation atrial tachyarrhythmias, mostly atrial fibrillation, are frequently observed after cavotricuspid isthmus ablation for typical atrial flutter, motivating an evaluation of concomitant or isolated pulmonary vein isolation.
Does pulmonary vein isolation with or without cavotricuspid isthmus ablation reduce atrial tachyarrhythmias in patients with typical atrial flutter compared to cavotricuspid isthmus ablation alone?
Meta-Analysis (n=902)
Does pulmonary vein isolation with or without cavotricuspid isthmus ablation reduce atrial tachyarrhythmias in patients with typical atrial flutter compared to cavotricuspid isthmus ablation alone?
Effect estimate: RR 0.57 (95% CI 0.41-0.79)
p-value: p=0.0007
In patients with typical atrial flutter, adding pulmonary vein isolation to cavotricuspid isthmus ablation significantly reduces the risk of subsequent atrial tachyarrhythmias, primarily driven by a reduction in atrial fibrillation.
Supports adding pulmonary vein isolation to cavotricuspid isthmus ablation in typical atrial flutter; strengthens randomized evidence for combined ablation.
Aims Cavotricuspid isthmus (CTI) ablation is the current ablation treatment for typical atrial flutter (AFL). However, post-ablation atrial tachyarrhythmias, mostly in the form of atrial fibrillation (AF), are frequently observed after CTI ablation. We aimed to evaluate the effectiveness and safety of concomitant or isolated pulmonary vein isolation (PVI) in patients with typical AFL scheduled for ablation. Methods and results Electronic databases (PubMED, EMBASE, Clinicaltrials.gov) were searched through July, 2024. Randomized controlled trials (RCTs) were eligible if comparing PVI ± CTI ablation vs. CTI alone. The primary outcomes were any sustained atrial arrhythmia, typical AFL relapse, and AF. Secondary outcomes were need for redo-ablation or antiarrhythmic drugs. Random-effects and fixed-effects meta-analyses were undertaken for each individual outcome. Seven RCTs, with a total of 902 patients, were included. Comparing to CTI ablation alone, PVI ± CTI was more effective in preventing atrial tachyarrhythmias [risk ratio (RR) = 0.57, 95% CI: 0.41–0.79, P = 0.0007, I2 = 50%, number needed to treat (NNT) = 4.1]. The results were driven mainly by a reduction of new onset/recurrent AF (RR = 0.41, 95% CI: 0.27–0.61, P < 0.0001, I2 = 0%, NNT = 3.3), whereas there were no differences in typical AFL relapse (RR = 1.52, 95% CI: 0.63–3.66, P = 0.35, I2 = 9%). Major complication rate was low and comparable across groups, although uncomplicated pericardial effusion was higher in PVI ± CTI (1.8% vs. 0.0%, P = 0.04). Results were comparable for the sub-analysis of PVI alone vs. CTI ablation. Conclusion In patients with typical AFL, PVI ± CTI ablation is more effective than CTI alone in reducing the atrial tachyarrhythmias and subsequent AF during follow-up, without affecting major complications rate. These results set the rationale for a well-designed, larger-scale RCT comparing both strategies.
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Gomes et al. (2024) conducted a meta-analysis in Typical atrial flutter (n=902). Pulmonary vein isolation (PVI) ± cavotricuspid isthmus (CTI) ablation vs. CTI ablation alone was evaluated on Any sustained atrial arrhythmia (RR 0.57, 95% CI 0.41-0.79, p=0.0007). Pulmonary vein isolation with or without cavotricuspid isthmus (CTI) ablation reduced atrial tachyarrhythmias compared to CTI alone in patients with typical atrial flutter (RR 0.57; 95% CI 0.41-0.79).
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