Prophylactic Cavotricuspid Isthmus Ablation in Atrial Fibrillation without Documented Typical Atrial Flutter: A Systematic Review and Meta-analysis

Abstract

Background: The advantage of prophylactic cavotricuspid isthmus (CTI) ablation for AF patients without documented atrial flutter is still unclear. The present study aimed to evaluate the role of prophylactic CTI ablation in this population. Methods: A systematic review and meta-analysis study was conducted. The overall effects estimation was conducted using random effects models. The pooled effects were presented as the risk difference and standardised mean difference for dichotomous and continuous outcomes, respectively. Results: A total of 1,476 patients from four studies were included. The risk of atrial tachyarrhythmias following a successful catheter ablation procedure was greater in the pulmonary vein isolation + CTI ablation group than pulmonary vein isolation alone group (34.8% versus 28.2%; risk difference 0.08; 95% CI [0.00–0.17]; p=0.04). Prophylactic CTI ablation was associated with a higher recurrent AF rate (33.8% versus 27.1%; risk difference 0.07; 95% CI [0.01–0.13]; p=0.02). Additional prophylactic CTI ablation to pulmonary vein isolation significantly increased the radio frequency application time (standardised mean difference 0.52; 95% CI [0.04–1.01]; p=0.03). Conclusion: This study suggested that prophylactic CTI ablation was an ineffective and inefficient approach in AF without documented typical atrial flutter patients.

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

“…17,18,25–27,48,49 Conversely, prophylactic catheter ablation of the CTI in patients without documented or inducible AFL likely has minimal benefit. 50 Alternatively, in 1 study, 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. 51 Several randomized trials have compared catheter ablation to AADs as first-line therapy for AF.…”

The endless fascination of right atrial flutter: Can we predict its occurrence?

“…More unexpected is the finding that larger right/left atrial volumes were not associated with the development of AFL on multivariate analysis; I suspect that the limited number of patients included in the study prevents a more detailed analysis that could yield a picture more adherent to the clinical reality. Assigning a precise cut‐off value of RACT for the future development of typical AFL is a “debatable” action, just in terms of “let's do cavotricuspid ablation” as an empirical and prophylactic maneuver 9 . In this regard, I'd be cautious, awaiting more robust and consistent data from larger population studies.…”

“…Assigning a precise cut-off value of RACT for the future development of typical AFL is a "debatable" action, just in terms of "let's do cavotricuspid ablation" as an empirical and prophylactic maneuver. 9 In this regard, I'd be cautious, awaiting more robust and consistent data from larger population studies. On the contrary, I give credit to the authors that longer RACT can be found in patients undergoing AF ablation and without clinical history of typical AFL.…”

Right atrial collision time (RACT): A novel marker of propensity for typical atrial flutter

“…Whereas ablation of the flutter circuit is indicated in patients with documented AFL, it is often considered in those without a documented AFL history, but high risk of unrecognized AFL or development of AFL in the future 5 . The practice of empiric flutter ablation is employed to prevent symptomatic recurrence and attenuate stroke risk in a group that may eventually present with thromboembolic complications as the first indication of AFL 6,7 . A simple diagnostic maneuver to determine the existence of a potential AFL circuit, and therefore a risk of occult or future AFL, would be very useful.…”

“…5 The practice of empiric flutter ablation is employed to prevent symptomatic recurrence and attenuate stroke risk in a group that may eventually present with thromboembolic complications as the first indication of AFL. 6,7 A simple diagnostic maneuver to determine the existence of a potential AFL circuit, and therefore a risk of occult or future AFL, would be very useful. This could support the decision on whether to empirically ablate a flutter circuit at time of ablation for other rhythms, such as atrial fibrillation.…”