Key result
Adding CTI ablation to PVI fails to reduce all-atrial arrhythmia recurrence versus PVI alone.
Why the study?
Despite evidence suggesting limited incremental benefit, prophylactic cavotricuspid isthmus ablation is routinely added to pulmonary vein isolation during catheter ablation of atrial fibrillation.
Does additional CTI ablation reduce the recurrence of all-atrial arrhythmias compared to PVI alone in patients with AF?
Meta-Analysis (n=1,400)
Does additional CTI ablation reduce the recurrence of all-atrial arrhythmias compared to PVI alone in patients with AF?
Effect estimate: RR 1.29 (95% CI 0.93-1.79)
p-value: p=.13
Additional CTI ablation during PVI does not reduce the recurrence of atrial arrhythmias in patients with AF, regardless of whether they have a history of typical atrial flutter.
Additional CTI ablation adds no benefit to PVI in AF; confirms lack of efficacy and supports PVI alone in practice and trials.
BACKGROUND: Pulmonary vein isolation (PVI) is the mainstay of catheter ablation (CA) for paroxysmal atrial fibrillation (AF). However, for persistent and long-standing persistent AF, there are no established strategies to improve the success rate of CA. Despite studies indicating that prophylactic cavotricuspid isthmus (CTI) ablation provides no or limited incremental benefit in patients with AF, it is still routinely performed worldwide. OBJECTIVE: We sought to examine whether CTI ablation for AF is associated with improvement in recurrence of all-atrial arrhythmias, compared with PVI alone in patients with and without typical atrial flutter (AFL). METHODS: A systematic review of PubMed, Cochrane, and Embase was performed for clinical studies including AF patients, reporting outcomes of CTI + PVI versus PVI alone. The primary efficacy endpoint was recurrence of all-atrial arrhythmias. RESULTS: Five studies comprising 1400 patients undergoing CTI + PVI versus PVI alone were included; 1110 patients had AF without AFL, and 290 patients had coexistent AF and AFL. After a mean follow-up of 14.4 ± 4.8 months, CTI + PVI was not associated with improvement in recurrence of all-atrial arrhythmias when compared with PVI alone (risk ratio [RR]: 1.29; 95% confidence interval [CI]: 0.93-1.79;p = .13). In the subgroup analysis, there were no differences between both groups in patients with AF without AFL (RR: 1.55; 95% CI: 0.96-2.48; p = .07), and in patients with AF and AFL (RR: 0.91; 95% CI: 0.6-1.39; p = .68). CONCLUSION: In AF patients, irrespective of the presence of typical AFL, additional CTI ablation is not associated with improvement in recurrence of all-atrial arrhythmias, compared with PVI alone.
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Romero et al. (2020) conducted a meta-analysis in Atrial fibrillation with or without typical atrial flutter (n=1,400). Cavotricuspid isthmus (CTI) ablation + Pulmonary vein isolation (PVI) vs. PVI alone was evaluated on recurrence of all-atrial arrhythmias (RR 1.29, 95% CI 0.93-1.79, p=.13). Additional cavotricuspid isthmus ablation with pulmonary vein isolation did not improve recurrence of all-atrial arrhythmias compared with PVI alone (RR 1.29; 95% CI 0.93-1.79; p=0.13).
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