Additional cavotricuspid isthmus block ablation may not improve the outcome of atrial fibrillation ablation

Abstract

Aims Pulmonary vein isolation (PVI) is an effective procedure for atrial fibrillation (AF). The role of additional cavotricuspid isthmus (CTI) block ablation remains controversial in AF patients without atrial flutter (AFL). Therefore, this study aimed to explore the clinical outcome of additional CTI block ablation in patients without AFL. Methods Between January 2013 and December 2017, a total of 139 patients who did not have documented AFL and who underwent catheter ablation for AF were recruited. Fifty‐seven patients were classified in additional CTI block ablation group and 82 patients were classified in without CTI group. The incidence of early‐onset and late‐onset atrial arrhythmia recurrence was compared between the two groups. Results The additional CTI group had a higher prevalence of persistent or long‐standing AF and larger left atrial volume. The additional CTI group had a higher incidence of late‐onset atrial arrhythmia recurrence (38.6% vs 12.2%; P < .001). When compared to without CTI group, additional CTI therapy did not have a better outcome in terms of freedom of atrial arrhythmia in subgroup analysis. The incidence of early‐onset and late‐onset atrial arrhythmia recurrence did not differ between additional CTI group and without CTI group in paroxysmal AF patients and nonparoxysmal AF patients after propensity scoring matching. Conclusion CTI block ablation in addition to PVI for AF patients without a history of AFL or inducible AFL during ablation may not improve the clinical outcome of AF ablation in the patients with larger LA volume, nonparoxysmal AF, or post‐PVI inducible AF.

Electrophysiological significance of the interatrial conduction including cavo‐tricuspid isthmus during atrial fibrillation

“…This finite difference method has already been well validated in other existing studies (Liszka & Orkisz, 1980;Zozor et al 2003). Although we documented the beneficial effects of a cavo-tricuspid isthmus ablation in addition to the pulmonary vein isolation during AF catheter ablation in both simulation and clinical studies, these results cannot be generalized, and other clinical studies have shown opposite outcomes (Moreira et al 2007;Pontoppidan et al 2009;Mesquita et al 2018;Lee et al 2019). In the AF ablation procedure, additional cavo-tricuspid isthmus ablation may be more helpful in a paroxysmal type with accompanying atrial flutter, or atrial dimension close to normal.…”

“…and Pontoppidan et al (2009) published the only existing randomized clinical trial regarding this issue. They reported that the additional cavo-tricuspid isthmus ablation during AF catheter ablation did not improve the rhythm outcome (Pontoppidan et al 2009;Mesquita et al 2018;Lee et al 2019). Nevertheless, those studies excluded patients with clinically documented atrial flutter, the percentage of persistent AF was higher, and the left atrial size was significantly greater than that in the patients included in this study.…”

“…Cavo-tricuspid isthmus ablation in the AF ablation procedure AF and atrial flutter commonly coexist, and patients often undergo circumferential pulmonary vein isolation and additional cavo-tricuspid isthmus ablation during the same procedure to prevent atrial flutter, and to reduce recurrent atrial arrhythmias after AF ablation or AF surgery (Onorati et al 2008;Waldo & Feld, 2008;Gwag et al 2019). However, other clinical studies have shown opposite results in which an additional cavo-tricuspid isthmus ablation does not affect the rhythm outcome of AF catheter ablation (Moreira et al 2007;Pontoppidan et al 2009;Mesquita et al 2018;Lee et al 2019). We compared and presented the previous publications regarding the usefulness of cavo-tricuspid isthmus ablation during AF ablation in Table 5.…”

Empirical cavo‐tricuspid isthmus line during ablation of atrial fibrillation: Enough is enough!

“…When compared to without CTI group, additional CTI line did not have a better outcome in terms of freedom of all-atrial arrhythmia in subgroup analysis. The incidence of early-onset and late-onset atrial arrhythmia recurrence did not differ between additional CTI group and without CTI group in paroxysmal AF patients and non-paroxysmal AF patients even after propensity scoring matching 4. Albeit, these results are not novel, they are clinically relevant due to the fact that empirical CTI lines during AF ablation procedures are still routinely performed worldwide.…”

“…2 Lee et al, in this issue of PACE conducted a retrospective study with a total of 139 patients without documented AFL and who underwent catheter ablation for AF. The incidence of early-onset and lateonset atrial arrhythmia recurrence was compared between the twogroups 4. The additional CTI group had a higher prevalence of persistent or long-standing AF and larger left atrial volume.…”