Ablation of Atrial Fibrillation at the Time of Cavotricuspid Isthmus Ablation in Patients With Atrial Flutter Without Documented Atrial Fibrillation Derives a Better Long-Term Benefit

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter

OBJECTIVE

We aimed to compare cryoballoon pulmonary vein isolation (PVI) with standard radiofrequency cavotricuspid isthmus (CTI) ablation as first-line treatment for typical atrial flutter (AFL).

METHODS

Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter was an international, multicentre, open with blinded assessment trial. Patients with CTI-dependent AFL and no documented atrial fibrillation (AF) were randomised to either cryoballoon PVI alone or radiofrequency CTI ablation. Primary efficacy outcome was time to first recurrence of sustained (>30 s) symptomatic atrial arrhythmia (AF/AFL/atrial tachycardia) at 12 months as assessed by continuous monitoring with an implantable loop recorder. Primary safety outcome was a composite of death, stroke, tamponade requiring drainage, atrio-oesophageal fistula, pacemaker implantation, serious vascular complications or persistent phrenic nerve palsy.

RESULTS

Trial recruitment was halted at 113 of the target 130 patients because of the SARS-CoV-2 pandemic (PVI, n=59; CTI ablation, n=54). Median age was 66 (IQR 61-71) years, with 98 (86.7%) men. At 12 months, the primary outcome occurred in 11 (18.6%) patients in the PVI group and 9 (16.7%) patients in the CTI group. There was no significant difference in the primary efficacy outcome between the groups (HR 1.11, 95% CI 0.46 to 2.67). AFL recurred in six (10.2%) patients in the PVI arm and one (1.9%) patient in the CTI arm (p=0.116). Time to occurrence of AF of ≥2 min was significantly reduced with cryoballoon PVI (HR 0.46, 95% CI 0.25 to 0.85). The composite safety outcome occurred in four patients in the PVI arm and three patients in the CTI arm (p=1.000).

CONCLUSION

Cryoballoon PVI as first-line treatment for AFL is equally effective compared with standard CTI ablation for preventing recurrence of atrial arrhythmia and better at preventing new-onset AF.

TRIAL REGISTRATION NUMBER

NCT03401099.

Elevated Left Atrial Volume Index Predicts Incident Atrial Fibrillation After Typical Right Atrial Flutter Ablation

Purpose

Incident atrial fibrillation (AF) is common after cavotricuspid isthmus (CTI) dependent atrial flutter (AFL) ablation. Risk factors for the development of AF post ablation are not well understood. The purpose of this study was to identify patients undergoing CTI ablation for AFL most likely to develop AF.

Methods

Retrospective chart review identified 114 consecutive patients without a history of AF or prior cardiac surgery who underwent typical CTI dependent AFL ablation between December 2013 to November 2018, who also had a complete preoperative transthoracic echocardiogram, and at least 1 year of follow-up at our medical center. We evaluated baseline characteristics, electrophysiology study (EPS) data and echocardiographic data for incidence of AF within 3 years.

Results

Incident AF was identified in 46 patients (40%) during 600 + 405 days follow-up. Left atrial volume index (LAVI) was significantly greater in patients who developed AF compared to those that did not (37 ± 12.2 ml/m² vs 30 ± 13.4 ml/m², p=.004), with an area under the receiver operator characteristic curve based on the LAVI of 0.7 (p = 0.004). Kaplan-Meier estimated incidence of AF was significantly greater in patients with LAVI ≥ 30 ml/m² than LAVI < 30 ml/m² (66% vs 27%, p=0.004). Risk of incident AF in patients with LAVI > 40 mL/m2 was similar to that of LAVI 30-40 ml/m2 (67% vs 63%, respectively, p=0.97). In multivariable analysis LAVI remained the sole independent predictor of incidence AF after CTI AFL ablation.

Conclusions

LAVI ≥ 30 ml/m² is associated with significantly increased risk of incident AF following CTI ablation for typical AFL. HATCH <2 was notably not an independent predictor of AF after AFL ablation.

Preventing atrial fibrillation by combined right isthmus ablation and cryoballoon pulmonary vein isolation in patients with typical atrial flutter: PAF-CRIOBLAF study

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

Of the patients enrolled, 36 were included in each group. At 2-year follow-up, the atrial fibrillation recurrence rate was significantly higher in the CTI vs CTI+group (25/36, 69% vs. 12/36, 33% respectively; P < .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.

Prospective Evaluation of a Standardized Screening for Atrial Fibrillation after Ablation of Cavotricuspid Isthmus Dependent Atrial Flutter

Aims: We aimed to prospectively investigate the effectiveness of a standardized follow-up for AF-detection after common atrial flutter (cAFL) ablation. Methods: A total of 309 patients after cAFL ablation without known AF, from 5 centers, and at least one completed, standardized follow-up at 3, 6 and 12 months, including a 24 h Holter-electrocardiogram (ECG), were included. The primary outcome was incident atrial fibrillation (AF), or atrial tachycardia (AT). Predictors were investigated by Cox proportional-hazards models. Results: The mean age was 67.9 years; 15.2% were female and the mean CHA₂DS₂-VASc (Congestive heart failure, Hypertension, Age, Diabetes, Stroke, Vascular disease, Sex category) score was 2.4 points. The great majority of patients (90.3%) were anticoagulated. Over a mean follow-up of 12.2 months with a standardized approach, AF/AT was detected in 73 patients, corresponding to 11.7% at 3 months, 18.4% at 6 months and 28.2% at 12 months of follow-up. AF was found in 64 patients, AT in 9 and both in 2 patients. Occurrence of AF was recorded in 40 (60.6%) patients by Holter-ECG and in the remaining 26 (39.4%) by clinical follow-up only. There was no difference in male versus female (p = 0.08), or in younger versus older patients (p = 0.96) for AF/AT detection. Only coronary artery disease (hazard ratio [95% confidence intervals] 1.03 [1.01–1.05], p = 0.01) was associated with the primary outcome. Conclusions: AF or AT was detected in a large proportion of cAFL patients after cavotricuspid-isthmus (CTI) ablation, using a standardized follow-up over 1 year. This standardized screening can be easily implemented with high patient acceptance. The high proportion of post-ablation AF needs to be taken into consideration when deciding on long-term oral anticoagulation.

Incidence, duration, pattern, and burden of de novo atrial arrhythmias detected by continuous ECG monitoring using an implantable loop recorder following ablation of the cavotricuspid isthmus

Background

Following cavotricuspid isthmus (CTI) ablation, many patients with atrial flutter (AFL) are diagnosed with atrial fibrillation (AF). The incidence, duration, pattern, and burden of AF remain undefined. These may have implications for the management of these patients.

Objective

To classify the incidence, duration, pattern, and burden of AF/AFL using an implantable loop recorder (ILR) after CTI ablation.

Methods

We enrolled consecutive patients with CTI-dependent AFL, no known history of AF, and CHA₂DS₂-VASc ≥ 2. An ILR was implanted before or within 90 days of ablation. The time to first AF/AFL, pattern, duration, and burden of longest AF/AFL were determined. Five distinct AF/AFL cohorts were identified: no AF/AFL and those with recurrences of isolated, clustered, frequent, or persistent AF/AFL.

Results

Fifty-two patients (81% male; 73 ± 9 years; CHA₂DS₂-VASc 3.7 ± 1.2) were followed for 784 (interquartile range [IQR] 263, 1150) days. AF/AFL occurred in 44 (85%) patients at 64 (IQR 8, 189) days post-CTI ablation and was paroxysmal in 31 (70%) patients (burden 0.6% [IQR 0.1, 4.8]). AF/AFL was isolated (n = 5, 11%), clustered (n =7, 16%), frequent (n =19, 43%), and persistent (n =13, 30%). The longest AF episode was <24 hours in 27 (61%) patients.

Conclusion

Following CTI ablation in AFL patients, although AF/AFL occurs in most patients, the burden is low and episodes were <24 hours in the majority of patients. Additional studies are needed to determine whether long-term electrocardiographic monitoring can help guide management of patients undergoing CTI ablation.

Cavotricuspid isthmus line in patients undergoing catheter ablation of atrial fibrillation with or without history of typical atrial flutter: A meta-analysis

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.

Symptoms and quality of life in patients with coexistent atrial fibrillation and atrial flutter

Aims

Atrial fibrillation (AF) and atrial flutter (AFL) are two of the most common atrial arrhythmias and often coexist. Many patients with AF or AFL are symptomatic, which impacts their quality of life (QoL). The purpose of this study was to determine whether coexistent AFL represents an added burden for AF patients.

Methods

We combined baseline data from two large prospective, observational, multicenter cohort studies (BEAT-AF and Swiss-AF). All 3931 patients included in this analysis had documented AF. We obtained information on comorbidities, medication, and lifestyle factors. All participants had a clinical examination and a resting ECG. Symptom burden and QoL at the baseline examination were compared between patients with and without coexistent AFL using multivariable adjusted regression models.

Results

Overall, 809 (20.6%) patients had a history of AFL. Patients with coexistent AFL more often had history of heart failure (28% vs 23%, p = 0.01), coronary artery disease (30% vs 26%, p = 0.007), failed therapy with antiarrhythmic drugs (44% vs 29%, p < 0.001), and more often underwent AF-related interventions (36% vs 17%, p < 0.001). They were more often symptomatic (70% vs 66%, p = 0.04) and effort intolerant (OR: 1.14; 95% CI: 1.01-1.28; p = 0.04). Documented AFL on the baseline ECG was associated with more symptoms (OR: 2.30; 95% CI: 1.26-4.20; p = 0.007).

Conclusion

Our data indicates that patients with coexistent AF and AFL are more often symptomatic and report poorer quality of life compared to patients suffering from AF only.

Prophylactic pulmonary vein isolation in typical atrial flutter patients without atrial fibrillation: a systematic review and meta-analysis of randomized trials

BACKGROUND

New-onset atrial fibrillation (AF) is common after cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) ablation. The meta-analysis was conducted to evaluate the benefit of prophylactic pulmonary vein isolation (PVI) in typical AFL patients.

METHODS

Randomized controlled trials (RCT) comparing prophylactic PVI to CTI ablation alone in typical AFL patients without prior documentation of AF were identified in the MEDLINE, EMBASE, and Cochrane databases.

RESULTS

Four RCTs met the inclusion criteria. A total of 357 patients with follow-up of 20 ± 9 months were included. More patients in prophylactic PVI group were free from atrial arrhythmias (AA) compared with those in CTI group (69% versus 50%, OR = 2.36, 95% CI: 1.51 to 3.68; P = 0.0001). In the subgroup of age > 55, prophylactic PVI showed even higher incidence of freedom from AA. There is a lower occurrence of AF in prophylactic PVI group (27% versus 46%, OR = 0.45, 95% CI: 0.28 to 0.73; P = 0.001) and no difference of complications between prophylactic PVI group and CTI group (4% versus 2%; P = 0.33).

CONCLUSION

Our study indicated the efficacy and safety of prophylactic PVI during CTI ablation in typical AFL patients without AF history, especially for elder patients. Large prospective RCTs are warranted to confirm the benefit of prophylactic PVI in typical AFL.

Cryoballoon pulmonary vein isolation as first line treatment for typical atrial flutter (CRAFT): study protocol for a randomised controlled trial

Purpose

Treatment of typical atrial flutter (AFL) with cavo-tricuspid isthmus (CTI) ablation is associated with a high occurrence rate of new onset atrial fibrillation (AF) during follow-up. There are data to support the addition of pulmonary vein isolation (PVI) to CTI ablation in patients with both AF and AFL, but the role of cryoballoon PVI only, with no CTI ablation, in AFL patients with no prior documentation of AF has not been studied.

Methods

CRAFT is an international, prospective, randomised, open with blinded assessment, multicentre superiority study comparing radiofrequency CTI ablation and cryoballoon PVI in patients with typical AFL. Participants with typical AFL are randomised in a 1:1 ratio to either treatment arm, with patients randomised to PVI not receiving CTI ablation. Post-procedural cardiac monitoring is performed using an implantable loop recorder. The primary endpoint is time to first recurrence of sustained symptomatic atrial arrhythmia. Key secondary endpoints include (1) total arrhythmia burden at 12 months, (2) time to first episode of AF lasting ≥ 2 min, (3) time to recurrence of AFL or AT and (4) procedural and fluoroscopy times. The primary safety endpoint is the composite of death, stroke/transient ischaemic attack, cardiac tamponade requiring drainage, atrio-oesophageal fistula, requirement for a permanent pacemaker, serious vascular complications requiring intervention or delaying discharge and persistent phrenic nerve palsy lasting > 24 h.

Conclusion

This study compares the outcomes of 2 different approaches to typical AFL—the conventional ‘substrate’-based strategy of radiofrequency CTI ablation versus a novel ‘trigger’-based strategy of cryoballoon PVI.

Trial registration

(ClinicalTrials.gov ID: NCT03401099)

Electronic supplementary material

The online version of this article (10.1007/s10840-020-00746-6) contains supplementary material, which is available to authorized users.

Cardiac magnetic resonance-derived right atrial functional analysis in patients with atrial fibrillation and typical atrial flutter

BACKGROUND

Typical atrial flutter (AFL) often occurs in patients with atrial fibrillation (AF). Decision-making tools for application of prophylactic cavo-tricuspid isthmus (CTI) ablation at the time of AF ablation may improve outcomes. In this study, we sought to define the right atrial (RA) functional characteristics of AF patients with documented typical AFL.

METHODS

Consecutive patients that underwent cardiac magnetic resonance (CMR) prior to initial AF ablation in the Johns Hopkins Hospital were enrolled. The AF database was reviewed to identify prevalent and incident documented typical AFL. Feature tracking CMR analysis during sinus rhythm was utilized to quantify RA longitudinal strain and strain rate, as well as RA passive and active emptying fractions derived from phasic RA volumes.

RESULTS

A total of 115 patients were analyzed (mean age 59.1 ± 11.4 years, 78.3% male, 74.8% paroxysmal AF). Of all patients, 30 (26.1%) had typical AFL. Clinical characteristics and AF type did not differ among groups defined by the absence or presence of typical AFL. In contrast, RA longitudinal strain (41.6 ± 16.8% vs. 55.8 ± 17.1%, p ≤ 0.001), systolic strain rate (1.71 ± 0.85 s^-1 vs. 2.33 ± 0.93 s^-1, p = 0.002), and late diastolic strain rate (1.78 ± 1.02 s^-1 vs. 2.50 ± 0.91 s^-1 p ≤ 0.001) were significantly lower in patients with typical AFL. Although RA passive emptying fraction was similar among groups (18.9 ± 8.1 vs. 19.5 ± 8.0, p = 0.75), RA active emptying fraction was lower in patients with typical AFL (34.8 ± 12.3 vs. 40.8 ± 12.1, p = 0.02).

CONCLUSIONS

The reservoir and pump function of the RA is significantly reduced in patients with typical AFL. Prophylactic CTI ablation warrants further study as adjunctive therapy to AF catheter ablation in selected patients with RA dysfunction.

Additional cavotricuspid isthmus ablation may reduce recurrent atrial tachyarrhythmia after total thoracoscopic ablation for persistent atrial fibrillation

OBJECTIVES

Unlike catheter ablation, little is known about the benefits of cavotricuspid isthmus (CTI) ablation in total thoracoscopic ablation (TTA) of atrial fibrillation (AF). This study aimed to investigate the incidence of recurrent atrial tachyarrhythmia (ATa) according to additional CTI ablation after TTA in patients with persistent AF.

METHODS

Among 208 consecutive patients who underwent TTA for persistent AF at the Samsung Medical Center from February 2012 to January 2016, a total of 63 patients with CTI ablation and 91 patients without CTI ablation were included in the final analysis. CTI ablation was performed in patients who had long-standing AF or atrial flutter episodes during the admission period.

RESULTS

There was no difference in baseline characteristics between the CTI ablation and non-CTI ablation groups, except for a higher number of male patients in the CTI ablation group. The CTI ablation group showed a significantly higher survival rate free from recurrent ATa than that of the non-CTI ablation group at 5 years (52.5% vs 41.4%, P = 0.046). In the multivariable analysis, CTI ablation (hazard ratio 0.46, 95% confidence interval 0.217-0.971; P = 0.042) and left atrial volume index (hazard ratio 1.05, 95% confidence interval 1.029-1.070; P < 0.001) were significantly correlated with recurrent ATa.

CONCLUSIONS

Patients with CTI ablation showed a better survival rate free from recurrent ATa compared with the non-CTI ablation group. The additional CTI ablation may reduce recurrent ATa after TTA in patients with documented atrial flutter or long-standing AF.

A Retrospective Study of Atrial Fibrillation Following Cavotricuspid Isthmus Ablation for Atrial Flutter

Background

Catheter radiofrequency ablation for typical atrial flutter is considered to be safe and effective. However, atrial fibrillation (AF) following cavotricuspid isthmus ablation for atrial flutter has been reported in patients without a previous history of AF, which has implications for the decision to use oral anticoagulation. This retrospective study at a single center aimed to evaluate the occurrence of AF in patients after successful cavotricuspid isthmus ablation of typical atrial flutter and to determine the incidence and associations with AF during follow-up.

Material/Methods

Between January 2011 and July 2017, of 110 consecutive patients who underwent cavotricuspid isthmus ablation for typical atrial flutter, 67 patients had no previous history of AF, of which 40 patients underwent follow-up. The 40 patients included in this retrospective clinical study included 34 men and 6 women, with a mean age of 67±10 years.

Results

Forty patients underwent post-ablation follow-up for 46±23 months, and 12 patients (30%) developed AF; six patients (15%) experienced recurrent of atrial flutter. More than half of the patients with post-ablation AF were asymptomatic with a European Heart Rhythm Association (EHRA) score of 1, and univariate analysis showed the absence of variables associated with the prevalence of AF.

Conclusions

Following cavotricuspid isthmus ablation for atrial flutter, recurrence of atrial flutter was found in 15% of cases, and asymptomatic AF occurred in 30%. These findings have implications for the use of post-ablation oral anticoagulation treatment, which is often discontinued following ablation therapy and before patient follow-up.

Prophylactic pulmonary vein isolation during cavotricuspid isthmus ablation for atrial flutter: A meta-analysis

BACKGROUND

Atrial arrhythmias (AA), including atrial fibrillation (AF), have been reported in patients after cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFL). Several studies have examined the effect of performing concomitant pulmonary vein isolation (PVI) with CTI on recurrent AA. These studies were analyzed to determine the overall effect of this approach on recurrent AA.

METHODS

PubMed and Google Scholar were searched for randomized trials comparing the incidence of AA after CTI versus CTI + PVI until June 2018. Only patients without prior history of AF were included in the recurrent AA analysis. All patients were included in the analyses of other clinical outcomes.

RESULTS

Four randomized control trials were included in the meta-analysis. In the recurrent AA analysis, a total of 314 patients were randomized in the studies (n = 158 CTI, n = 156 CTI + PVI). Freedom from AA at 1 year was significantly higher in the CTI + PVI group versus CTI alone (odds ratio [OR] 0.25 [0.14, 0.44] 95% confidence interval [CI], P < 0.00001). A total of 550 patients (n = 336 CTI, n = 214 CTI + PVI) were included in analyses for procedure time, fluoroscopy time, and complications rates. Procedure time and fluoroscopy time were significantly longer in the CTI + PVI group (mean difference [MD]: 103.31 min [94.40, 112.23] 95% CI, P < 0.00001) and (MD: 16.47 min [14.89, 18.05] 95% CI, P < 0.00001), respectively. Total complications were statistically similar between groups.

CONCLUSION

This meta-analysis shows addition of a prophylactic PVI during CTI ablation significantly reduces recurrent AA at 1 year without significantly increasing major complications.

Impact of prophylactic cavotricuspid isthmus ablation in atrial fibrillation recurrence after a first pulmonary vein isolation procedure

INTRODUCTION

PVI is a well-established therapy for patients with drug refractory atrial fibrillation (AF). However, it remains unclear whether prophylactic cavotricuspid isthmus (CTI) ablation at the time of PVI improves long-term freedom from AF.

OBJECTIVE

To compare the outcomes of patients who underwent PVI alone vs. PVI + prophylactic CTI ablation.

METHODS

Propensity score (PS) matching analysis based on a registry dataset of 1931 consecutive patients who underwent a first AF catheter ablation. After excluding those with documented/inducible atrial flutter (n = 233), 1698 individuals were available for matching. Following adjustment for age, gender, body mass index (BMI), hypertension, smoking, diabetes, LA volume, type of AF, and type of navigation (magnetic vs. manual), PS matched 411 patients who underwent PVI + CTI ablation with 411 receiving PVI alone.

RESULTS

PS analysis yielded a study population of 822 matched patients (58 ± 11 years, 69% males, 64% with paroxysmal AF). Over a median 2 years follow-up period there were 278 AF recurrences (34%). Survival free of AF (Log rank p = .965) and annual relapse rates were similar in the two groups - 10.9%/year vs 10.1%/year (PVI vs PVI + CTI, respectively, p = .97). CTI ablation remained unassociated with AF-free survival (HR 1.09, 95%CI: 0.84-1.41, p = .54) after Cox regression adjustment for age, sex, type of AF, LA volume, hypertension, diabetes, BMI and center. Female gender, current smoking, indexed LA volume and non-paroxysmal AF were identified as independent predictors of relapse after matching.

CONCLUSIONS

Prophylactic CTI ablation at the time of a first PVI does not seem to improve long-term freedom from AF.

Prophylactic Atrial Fibrillation Ablation in Atrial Flutter Patients without Atrial Fibrillation: A Meta-Analysis with Trial Sequential Analysis

Background

New-onset atrial fibrillation (AF) is common after atrial flutter (AFL) ablation, but it was unclear whether AF ablation could reduce the incidence of AF in AFL patients without AF history. The present meta-analysis was conducted to evaluate the benefit of prophylactic AF ablation in reducing the occurrence of AF in typical AFL patients.

Material/Methods

We systematically searched PubMed, EMBASE, and the Cochrane Library from inception to December 2017 for randomized controlled trials (RCTs) that assessed the efficacy of AF ablation in reducing the occurrence of AF in AFL patients without AF. Trial sequential analysis (TSA) was used to control random errors and calculate the required information size.

Results

Four trials (n=357 patients) met the inclusion criteria and were included in our meta-analysis. The incidence of AF after AFL ablation was 46.4%. We observed that prophylactic AF ablation reduced the AF incidence compared with simple AFL ablation (26.1% versus 46.4%, RR: 0.57, 95% CIs: 0.42–0.76, P=0.0002) with a prolonged procedure duration (P<0.00001) and fluoroscopy time (P=0.004). Further TSA indicated that more RCTs were needed to reach more conclusive results. There was no significant difference in clinical complications (P=0.33) between the 2 groups.

Conclusions

This meta-analysis provides evidence that prophylactic AF ablation may be more effective than simple AFL ablation in reducing AF incidence after AFL ablation. Large prospective RCTs are warranted to confirm the benefit of prophylactic AF ablation in AFL patients without AF history.

Incidence of new-onset atrial fibrillation after cavotricuspid isthmus ablation for atrial flutter

Aims

In patients with cavotricuspid isthmus (CTI) ablation for atrial flutter (AFL), the decision to hold oral anticoagulation (OAC) often becomes an issue. The purpose of this study was to describe the incidence of the development of atrial fibrillation (AF) after CTI ablation in patients with documented AFL with and without a previous history of AF and to identify risk predictors for the occurrence of AF after CTI.

Methods and results

We included 364 consecutive patients undergoing successful CTI ablation. Thereof, 230 patients (170 male; age 66 ± 11 years) had AFL only (AFL group) and 134 patients (94 male; age 65 ± 11 years) had AFL and previously documented AF (AFL and AF group). Over a mean follow-up of 22 ± 20 months, 163 (71%) patients in the AFL group and 67 (50%) patients in the AFL and AF groups had no documentation of a recurrent atrial arrhythmia (P < 0.001). AF developed in 51 patients (22%) in the AFL group and in 57 (43%) patients in the AFL and AF groups (P < 0.001). In patients without history of AF, left atrial diameter was the only predictor of development of AF (HR 1.058 [95%CI 1.011-1.108], P = 0.016). Multivariate analysis of the total population identified history of AF (HR 1.918 [95%CI 1.301-2.830], P = 0.001) and BMI as predictors for AF development (HR 1.052 [95%CI 1.012-1.093], P = 0.011).

Conclusion

Our results indicate that new-onset AF develops in a significant proportion of patients undergoing CTI for AFL. One should therefore be careful to withhold OAC. Furthermore, pulmonary vein isolation should be considered in conjunction with CTI, particularly in patients with previously documented AF.

New-onset atrial fibrillation after cavotricuspid isthmus ablation: identification of advanced interatrial block is key

AIMS

A significant proportion of patients develop atrial fibrillation (AF) following cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFl). The objective of this study was to assess whether the presence of advanced interatrial block (aIAB) was associated with an elevated risk of AF after CTI ablation in patients with typical AFl and no prior history of AF.

METHODS AND RESULTS

This study included patients with typical AFl and no prior history of AF that were referred for CTI ablation. Patients were excluded when they had received repeat ablations or did not demonstrate a bidirectional block. In all patients, a post-ablation electrocardiogram (ECG) in sinus rhythm was evaluated for the presence of aIAB, defined as a P-wave duration ≥120 ms and biphasic morphology in the inferior leads. New-onset AF was identified from 12-lead ECGs, Holter monitoring, and device interrogations. The cohort comprised 187 patients (age 67 ± 10.7 years; ejection fraction 55.8 ± 11.2%). Advanced interatrial block was detected in 18.2% of patients, and left atrium was larger in patients with aIAB compared with those without aIAB (46.2 ± 5.9 vs. 43.1 ± 6.0 mm; P = 0.01). Over a median follow-up of 24.2 months, 67 patients (35.8%) developed new-onset AF. The incidence of new-onset AF was greater in patients with aIAB compared with those without aIAB (64.7 vs. 29.4%; P < 0.001). After a comprehensive multivariate analysis, aIAB emerged as the strongest predictor of new-onset AF [odds ratio (OR) 4.2, 95% confidence interval (CI): 1.9-9.3; P < 0.001].

CONCLUSION

Advanced interatrial block is a key predictor for high risk of new-onset AF after a successful CTI ablation in patients with typical AFl.

Outcomes after ablation for typical atrial flutter (from the Loire Valley Atrial Fibrillation Project)

Similar predisposing factors are found in most types of atrial arrhythmias. The incidence of atrial fibrillation (AF) among patients with atrial flutter is high, suggesting similar outcomes in patients with those arrhythmias. We sought to investigate the long-term outcomes and prognostic factors of patients with AF and/or atrial flutter with contemporary management using radiofrequency ablation. In an academic institution, we retrospectively examined the clinical course of 8,962 consecutive patients admitted to our department with a diagnosis of AF and/or atrial flutter. After a median follow-up of 934 ± 1,134 days, 1,155 deaths and 715 stroke and/thromboembolic (TE) events were recorded. Patients with atrial flutter undergoing cavotricuspid isthmus ablation (n = 875, 37% with a history of AF) had a better survival rate than other patients (hazard ratio [HR] 0.35, 95% confidence interval [CI] 0.25 to 0.49, p <0.0001). Using Cox proportional hazards model and propensity score model, after adjustment for main other confounders, ablation for atrial flutter was significantly associated with a lower risk of all-cause mortality (HR 0.55, 95% CI 0.36 to 0.84, p = 0.006) and stroke and/or TE events (HR 0.53, 95% CI 0.30 to 0.92, p = 0.02). After ablation, there was no significant difference in the risk of TE between patients with a history of AF and those with atrial flutter alone (HR 0.83, 95% CI 0.41 to 1.67, p = 0.59). In conclusion, in patients with atrial tachyarrhythmias, those with atrial flutter with contemporary management who undergo cavotricuspid isthmus radiofrequency ablation independently have a lower risk of stroke and/or TE events and death of any cause, whether a history of AF is present or not.