Key result
Adding PVI to CTI ablation cuts 2-year AF recurrence ~81% vs. CTI ablation alone.
Why the study?
Many patients develop atrial fibrillation after successful cavo-tricuspid isthmus ablation for typical atrial flutter, but whether concomitant pulmonary vein isolation reduces mid-to-long-term atrial fibrillation burden is unclear.
Does combined cavo-tricuspid isthmus ablation and pulmonary vein isolation reduce atrial fibrillation recurrence in patients with typical atrial flutter and prior atrial fibrillation?
RCT (n=72)
Open-label
1/1 ratio by block, with stratification by center
Yes
Does combined cavo-tricuspid isthmus ablation and pulmonary vein isolation reduce atrial fibrillation recurrence in patients with typical atrial flutter and prior atrial fibrillation?
Hazard Ratio: 0.19 (95% CI 0.07–0.43)
Absolute Event Rate: 33% vs 69%
p-value: p=9e-5
Performing prophylactic pulmonary vein isolation at the time of cavo-tricuspid isthmus ablation significantly reduces long-term atrial fibrillation recurrence in patients with typical atrial flutter and a history of AF.
Supports adding PVI to CTI ablation in typical AFL with prior AF; confirms prior trial benefit on 2-year recurrence.
BACKGROUND: Although less common, typical atrial flutter shares similar pathophysiological roots with atrial fibrillation. Following successful cavo-tricuspid isthmus ablation using radiofrequency, many patients, however, develop atrial fibrillation in the mid-to-long-term. This study sought to assess whether pulmonary vein isolation conducted at the same time as cavo-tricuspid isthmus ablation would significantly modify the atrial fibrillation burden upon follow-up in patients suffering from typical atrial flutter. METHODS: This was a multicenter randomized controlled study involving typical atrial flutter patients with history of non-predominant atrial fibrillation (1 atrial fibrillation episode only, in 67% of population) who were scheduled for cavo-tricuspid isthmus radiofrequency ablation. Patients were randomly assigned to either undergo cavo-tricuspid isthmus ablation alone or cavo-tricuspid isthmus plus pulmonary vein isolation (CTI+). Pulmonary vein isolation was performed using cryoballoon technology. An outpatient consultation with ECG and 1-week Holter monitoring was performed at 3, 6 months, 1 year, and 2 years postprocedure. The primary endpoint was atrial fibrillation recurrences lasting more than 30 s at 2 years postablation. RESULTS: < .001), with similar typical atrial flutter recurrence rates. There were no differences in undesirable events, except for transient phrenic nerve palsy reported from three CTI+patients (8.3%). CONCLUSION: Pulmonary vein isolation using cryoballoon technology was proven to significantly reduce the atrial fibrillation incidence at 2 years postcavo-tricuspid isthmus ablation.
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Anselme et al. (2021) conducted an RCT in Typical atrial flutter with history of non-predominant atrial fibrillation (n=72). Cavo-tricuspid isthmus ablation plus pulmonary vein isolation vs. Cavo-tricuspid isthmus ablation alone was evaluated on Atrial fibrillation recurrences lasting more than 30 s at 2 years postablation (HR 0.19, 95% CI 0.07-0.43, p=9e-5). Combined cavo-tricuspid isthmus ablation and pulmonary vein isolation reduced atrial fibrillation recurrence at 2 years compared to cavo-tricuspid isthmus ablation alone (HR 0.19, 95% CI 0.07-0.43, p=9e-5).
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