Randomized Study Comparing Combined Pulmonary Vein–Left Atrial Junction Disconnection and Cavotricuspid Isthmus Ablation Versus Pulmonary Vein–Left Atrial Junction Disconnection Alone in Patients Presenting With Typical Atrial Flutter and Atrial Fibrillation

Abstract

Background— Atrial flutter (AFL) and atrial fibrillation (AF) frequently coexist in the same patient. Recently it has been demonstrated that the triggers for both AF and AFL may originate in the pulmonary veins (PVs). We hypothesized that in patients with both AF and typical AFL, pulmonary vein–left atrial junction (PV-LAJ) disconnection may eliminate both arrhythmias. Methods and Results— Consecutive patients with documented symptomatic AF and typical AFL were randomly assigned to have PV-LAJ disconnection combined with cavotricuspid isthmus (CTI) ablation (group 1, n=49) or PV-LAJ disconnection alone (group 2, n=59). Within the first 8 weeks after ablation, 32 of the group 2 patients had typical AFL documented, whereas none was seen in group 1. Twenty of these 32 converted to sinus rhythm after initiating antiarrhythmic drugs (AADs). Twelve were cardioverted, and AADs were started. After 8 weeks, all AADS were stopped, and only 3 patients continued to have recurrent sustained typical AFL that was eliminated by CTI ablation. Beyond 8 weeks of follow-up, 7 patients in group 1 and 6 patients in group 2 (14% and 11%, respectively) continued to have AF. Ten of these 13 patients underwent a repeat PV-LAJ disconnection procedure and were cured. The remaining 3 remained in normal sinus rhythm while taking AADs. Conclusions— In patients with both AFL and AF, PV-LAJ disconnection alone may be sufficient to control both arrhythmias. CTI block reduced early postablation recurrence of arrhythmias, which in the majority of patients reflects a short-term clinical problem.

Results From a Single-Blind, Randomized Study Comparing the Impact of Different Ablation Approaches on Long-Term Procedure Outcome in Coexistent Atrial Fibrillation and Flutter (APPROVAL)

“…Between the 3 ablation approaches for coexistent AF and AFL, several studies have demonstrated that the combined ablation strategy (PVAI+CTI) results in very low AF recurrence, 14,15 that PVAI alone without CTI ablation has an early recurrence of AFL in 24%, 16 and that the rate of AF recurrence after CTI isolation alone has been reported to be as high as 80% and up to 30% in those on AADs after isthmus isolation. 16 Roithinger et al 17 hypothesized that AF organizes to AFL in patients presenting with both arrhythmias.…”

Ablação por radiofreqüência da fibrilação atrial paroxística: fatores determinantes da eficácia clínica a longo-prazo

“…Nonetheless, Bertaglia et al 17 showed clearly that the recurrence of AF after CTI block alone increases progressively over time. Wazni et al 18 randomized patients with AF and flutter in two groups, one of them only for PV isolation and the other for isolation plus CTI block, and observed, in a follow-up shorter than one year, that isolation alone was able to control both arrhythmias, although isthmus block could prevent the early recurrence of arrhythmias. In the present study, however, the association of isolation and CTI block reduced recurrences also in the long term.…”

Ablation of Atrial Fibrillation

“…The most common location is the roof between the right additional lines or PV isolation with complex fractionated electric potential ablation. 66 Even in unique subsets of AF population such as coexistent AF and typical atrial flutter 67,68 and AF and perimitral flutter, 69 isthmus lines were found to have limited impact on arrhythmia recurrence. Therefore, the benefits of linear lesions as an adjunctive therapy remain unclear.…”