Abstract
Background
Catheter ablation is recommended as first-line therapy for patients with symptomatic typical AFl. Although the conventional multi-catheter approach is the standard of care for cavotricuspid isthmus (CTI) ablation, a single-catheter approach was recently described as a feasible alternative. The present study sought to compare safety, efficacy, and efficiency of single vs. multi-catheter approach for atrial flutter (AFl) ablation.
Methods
In this randomized multi-center study, consecutive patients referred for AFl ablation (n = 253) were enrolled and randomized to multiple vs. single-catheter approach for CTI ablation. In the single-catheter arm, PR interval (PRI) on the surface ECG was used to prove CTI block. Procedural and follow-up data were collected and compared between the two arms.
Results
128 and 125 patients were assigned to the single-catheter and to the multi-catheter arms, respectively. In the single-catheter arm, procedure time was significantly shorter (37 ± 25 vs. 48 ± 27 minutes, p = 0.002) and required less fluoroscopy time (430 ± 461 vs. 712 ± 628 seconds, p < 0.001) and less radiofrequency time (428 ± 316 vs. 643 ± 519 seconds, p < 0.001), achieving a higher first-pass CTI block rate (55 (45%) vs. 37 (31%), p = 0.044), compared with the multi-catheter arm. After a median follow-up of 12 months, 11 (4%) patients experienced AFl recurrences (5 (4%) in the single-catheter arm and 6 (5%) in the multi-catheter arm, p = 0.99). No differences were found in arrhythmia-free survival between arms (log-rank = 0.71).
Conclusions
The single-catheter approach for typical AFl ablation is not inferior to the conventional multiple-catheter approach, reducing procedure, fluoroscopy, and radiofrequency time.
Graphical Abstract
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data availability
The data that support the findings of this study are available from the corresponding author, upon reasonable request.
Abbreviations
- AV:
-
Atrioventricular
- AF:
-
Atrial flutter
- CTI:
-
Cavotricuspid isthmus
- CS:
-
Coronary sinus
- ECG:
-
Electrocardiogram
- PRI:
-
PR interval
- RF:
-
Radiofrequency
References
Da Costa A, The ́venin J, Roche F, et al. Results from the Loire-Arde`che-Droˆme-Ise`re-Puy-de-Doˆme (LADIP) trial on atrial flutter, a multicentric prospective randomized study comparing amiodarone and radiofrequency ablation after the first episode of symptomatic atrial flutter. Circulation. 2006;114:1676–81.
Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016;133:e506–74.
Madaffari A, Krisai P, Spies F, et al. Ablation of typical atrial flutter guided by the paced PR interval on the surface electrocardiogram: a proof of concept study. Europace. 2019;21:1750–4.
Brugada J, Katritsis DG, Arbelo E, et al. ESC Scientific Document Group. 2019 ESC guidelines for the management of patients with supraventricular tachycardia the task force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2020;41(5):655–720.
Cosio FG, Lopez-Gil M, Goicolea A, et al. Radiofrequency ablation of the inferior vena cava-tricuspid valve isthmus in common atrial flutter. Am J Cardiol. 1993;71:705–9.
Feld GK, Fleck RP, Chen PS, et al. Radiofrequency catheter ablation for the treat- ment of human type 1 atrial flutter: identification of a critical zone in the re-entrant circuit by endocardial mapping techniques. Circulation. 1992;86:1233–40.
Spector P, Reynolds MR, Calkins H, et al. Meta-analysis of ablation of atrial flutter and supraventricular tachycardia. Am J Cardiol. 2009;104:671–7.
Laurent G, Bourcier A, Bertaux G, et al. A new and simple method for distinguishing complete from incomplete block through the cavotricuspid isthmus. J Interv Card Electrophysiol. 2005;14:175–82.
Sebag FA, Simeon E, Moubarak G, et al. Definition of success criteria for ablation of typical right atrial flutter with a single-catheter approach: a pilot study. Arch Cardiovasc Dis. 2020;113:791–6.
König S, Ueberham L, Schuler E, Wiedemann M, Reithmann C, Seyfarth M, Sause A, Tebbenjohanns J, Schade A, Shin DI, Staudt A, Zacharzowsky U, Andrié R, Wetzel U, Neuser H, Wunderlich C, Kuhlen R, Tijssen JGP, Hindricks G, Bollmann A. In-hospital mortality of patients with atrial arrhythmias: insights from the German-wide Helios hospital network of 161 502 patients and 34 025 arrhythmia-related procedures. Eur Heart J. 2018;39:3947–57.
Falasconi G, Penela D, Soto-Iglesias D, et al. A standardized stepwise zero-fluoroscopy approach with transesophageal echocardiography guidance for atrial fibrillation ablation. J Interv Card Electrophysiol. 2021;10.
Pambrun T, Combes S, Sousa P, et al. Contact-force guided single-catheter approach for pulmonary vein isolation: feasibility, outcomes, and cost-effectiveness. Heart Rhythm. 2017;14:331–8.
Heidbuchel H, Wittkampf FH, Vano E, et al. Practical ways to reduce radiation dose for patients and staff during device implantations and electrophysiological procedures. Europace. 2014;16:946–64.
Lickfett L, Mahesh M, Vasamreddy C, et al. Radiation exposure during catheter ablation of atrial fibrillation. Circulation. 2004;110:3003–10.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Ethics approval
This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by Ethics Committee of each center.
Conflict of interest
A. Berruezo is a stockholder of Galgo Medical. D. Soto-Iglesias is an employee of Biosense Webster. A. Berruezo received speaker fees from Biosense and research grants from Biotronik. P. Francia received speaker fees and research and educational grants from Boston Scientific and Abbott. The other authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Penela, D., Chauca, A., Fernández-Armenta, J. et al. Outcomes of cavotricuspid isthmus-dependent flutter ablation: randomized study comparing single vs. multiple catheter procedures—the SIMPLE study. J Interv Card Electrophysiol 66, 1979–1988 (2023). https://doi.org/10.1007/s10840-023-01511-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10840-023-01511-1