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Approaching a decade of cryo catheter ablation for type 1 atrial flutter—a meta-analysis and systematic review

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Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Purpose

Despite increasingly widespread use of cryo catheter ablation (CCA) in clinical practice, current ACC/AHA/ESC guidelines for management of supraventricular arrhythmias cite only radiofrequency catheter ablation (RFCA) as first-line treatment for type 1 atrial flutter (AFL). We performed a meta-analysis of efficacy and procedure outcomes from randomized controlled clinical trials comparing CCA with RFCA for type 1 AFL. A systematic review of non-randomized, single-arm clinical studies of CCA for type 1 AFL was also done.

Methods

An English language search of Medline, Cochrane, Embase, and an extensive bibliography search from January 2000 to May 2010 was conducted. Inclusion/exclusion criteria were met by six randomized clinical trials for meta-analysis (n = 341) and 13 non-randomized, single-arm clinical studies for systematic review (n = 763). Four primary outcomes were analyzed, namely, percent of patients with bidirectional conduction block (BCB) at procedure, proportion of patients who were asymptomatic during follow-up, procedure time, and fluoroscopy time.

Results

Random effect analyses for CCA versus RFCA favored the latter ablation modality for percent of patients with BCB at procedure (84.3% vs. 93.3%; OR = 0.51; p = 0.14). A similar proportion of patients were asymptomatic during follow-up (85.5% vs. 87.3%; OR = 0.68; p = 0.53). A significantly longer procedure time was determined for CCA (171.7 min vs. 134.5 min; Std diff means = 0.57; p < 0.001), but fluoroscopy time was similar for both (27.5 vs. 27.3 min; Std diff means = 0.12; p = 0.28). Sensitivity analyses revealed a shift in favor of CCA with large tip size catheters only versus RFCA for long-term effectiveness (OR = 1.5; p = 0.09).

Conclusions

Results from this meta-analysis and systematic review do not generally favor one ablation modality over another for treatment of type 1 AFL. Indeed, there is higher percent BCB at procedure and shorter procedure time with RFCA. However, chronic success and fluoroscopy time were similar for both ablation modalities. Ultimately, investigator experience, catheter costs, and patient preference may sway device selection in clinical practice.

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References

  1. Naccarelli, G. V., Varker, H., Lin, J., & Schulman, K. L. (2009). Increasing prevalence of atrial fibrillation and flutter in the United States. The American Journal of Cardiology, 104(11), 1534–1539.

    Article  PubMed  Google Scholar 

  2. Blomstrom-Lundqvist, C., Scheinman, M. M., Aliot, E. M., Alpert, J. S., Calkins, H., Camm, A. J., et al. (2003). ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias—executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. Journal of the American College of Cardiology, 42(8), 1493–1531.

    Article  PubMed  Google Scholar 

  3. Inama, G., Pedrinazzi, C., Adragao, P., Alvarez, M., Arribas, F., Bonhorst, D., et al. (2009). Five years of catheter ablation procedures in South-Western Europe: meta-analysis of National Registries. Pacing and Clinical Electrophysiology, 32(4), 506–515.

    Article  PubMed  Google Scholar 

  4. Andrew, P., & Montenero, A. S. (2007). Atrial flutter: a focus on treatment options for a common supraventricular tachyarrhythmia. Journal of Cardiovascular Medicine (Hagerstown), 8(8), 558–567.

    Article  Google Scholar 

  5. Berman, N. G., & Parker, R. A. (2002). Meta-analysis: neither quick nor easy. BMC Medical Research Methodology, 2, 10.

    Article  PubMed  Google Scholar 

  6. Montenero, A. S., Bruno, N., Antonelli, A., Mangiameli, D., Barbieri, L., Andrew, P., et al. (2005). Comparison between a 7 French 6 mm tip cryothermal catheter and a 9 French 8 mm tip cryothermal catheter for cryoablation treatment of common atrial flutter. Journal of Interventional Cardiac Electrophysiology, 13(1), 59–69.

    Article  PubMed  Google Scholar 

  7. Rodriguez, L. M., & Timmermans, C. (2004). Transvenous cryoablation of cardiac arrhythmias. Technology in Cancer Research & Treatment, 3(5), 515–524.

    Google Scholar 

  8. Petitti, D. B. (2001). Approaches to heterogeneity in meta-analysis. Statistics in Medicine, 20(23), 3625–3633.

    Article  PubMed  CAS  Google Scholar 

  9. Perez, F. J., Schubert, C. M., Parvez, B., Pathak, V., Ellenbogen, K. A., & Wood, M. A. (2009). Long-term outcomes after catheter ablation of cavo-tricuspid isthmus dependent atrial flutter: a meta-analysis. Circ Arrhythm Electrophysiol, 2(4), 393–401.

    Article  PubMed  Google Scholar 

  10. Spector, P., Reynolds, M. R., Calkins, H., Sondhi, M., Xu, Y., Martin, A., et al. (2009). Meta-analysis of ablation of atrial flutter and supraventricular tachycardia. The American Journal of Cardiology, 104(5), 671–677.

    Article  PubMed  Google Scholar 

  11. Montenero, A. S., Bruno, N., Antonelli, A., Mangiameli, D., Barbieri, L., Zumbo, F., et al. (2006). Low clinical recurrence and procedure benefits following treatment of common atrial flutter by electrogram-guided hot spot focal cryoablation. Journal of Interventional Cardiac Electrophysiology, 15(2), 83–92.

    Article  PubMed  Google Scholar 

  12. Laurent, V., Fauchier, L., Pierre, B., Grimard, C., & Babuty, D. (2009). Incidence and predictive factors of atrial fibrillation after ablation of typical atrial flutter. Journal of Interventional Cardiac Electrophysiology, 24(2), 119–125.

    Article  PubMed  Google Scholar 

  13. Moubarak, G., Pavin, D., Laviolle, B., Solnon, A., Kervio, G., Daubert, J. C., et al. (2009). Incidence of atrial fibrillation during very long-term follow-up after radiofrequency ablation of typical atrial flutter. Archives of Cardiovascular Diseases, 102(6–7), 525–532.

    Article  PubMed  Google Scholar 

  14. Leiria, T. L., Becker, G., Kus, T., Essebag, V., Hadjis, T., & Sturmer, M. L. (2010). Improved flutter ablation outcomes using a 10 mm-tip ablation catheter. Indian Pacing Electrophysiol J, 10(11), 496–502.

    PubMed  Google Scholar 

  15. Kuniss, M., Vogtmann, T., Ventura, R., Willems, S., Vogt, J., Gronefeld, G., et al. (2009). Prospective randomized comparison of durability of bidirectional conduction block in the cavotricuspid isthmus in patients after ablation of common atrial flutter using cryothermy and radiofrequency energy: the CRYOTIP study. Heart Rhythm, 6(12), 1699–1705.

    Article  PubMed  Google Scholar 

  16. Manusama, R., Timmermans, C., Pison, L., Philippens, S., Perez, D., & Rodriguez, L. M. (2009). Typical atrial flutter can effectively be treated using single one-minute cryoapplications: results from a repeat electrophysiological study. Journal of Interventional Cardiac Electrophysiology, 26(1), 65–72.

    Article  PubMed  Google Scholar 

  17. Pantos, I., Patatoukas, G., Katritsis, D. G., & Efstathopoulos, E. (2009). Patient radiation doses in interventional cardiology procedures. Current Cardiology Reviews, 5(1), 1–11.

    Article  PubMed  Google Scholar 

  18. Smith, P. N., Vidaillet, H., Sharma, P. P., Hayes, J. J., & Schmelzer, J. R. (2001). Catheter ablation in the elderly in the United States: use in the Medicare population from 1991 to 1998. Pacing and Clinical Electrophysiology, 24(1), 66–69.

    Article  PubMed  CAS  Google Scholar 

  19. Kimman, G. P., Theuns, D. A., Szili-Torok, T., Scholten, M. F., Res, J. C., & Jordaens, L. J. (2004). CRAVT: a prospective, randomized study comparing transvenous cryothermal and radiofrequency ablation in atrioventricular nodal re-entrant tachycardia. European Heart Journal, 25(24), 2232–2237.

    Article  PubMed  CAS  Google Scholar 

  20. Friedman, P. L., Dubuc, M., Green, M. S., Jackman, W. M., Keane, D. T., Marinchak, R. A., et al. (2004). Catheter cryoablation of supraventricular tachycardia: results of the multicenter prospective "frosty" trial. Heart Rhythm, 1(2), 129–138.

    Article  PubMed  Google Scholar 

  21. Timmermans, C., Ayers, G. M., Crijns, H. J., & Rodriguez, L. M. (2003). Randomized study comparing radiofrequency ablation with cryoablation for the treatment of atrial flutter with emphasis on pain perception. Circulation, 107(9), 1250–1252.

    Article  PubMed  Google Scholar 

  22. Collins, N. J., Barlow, M., Varghese, P., & Leitch, J. (2006). Cryoablation versus radiofrequency ablation in the treatment of atrial flutter trial (CRAAFT). Journal of Interventional Cardiac Electrophysiology, 16(1), 1–5.

    Article  PubMed  Google Scholar 

  23. Friedman, P. L. (2005). Catheter cryoablation of cardiac arrhythmias. Current Opinion in Cardiology, 20(1), 48–54.

    PubMed  Google Scholar 

  24. Johansson, B. I., Hrafnkelsdottir, T. J., & Edvardsson, N. (2007). ST segment elevation and chest pain during cryoablation of atrial flutter. Europace, 9(6), 407–410.

    Article  PubMed  Google Scholar 

  25. Movsowitz, C., Callans, D. J., Schwartzman, D., Gottlieb, C., & Marchlinski, F. E. (1996). The results of atrial flutter ablation in patients with and without a history of atrial fibrillation. The American Journal of Cardiology, 78(1), 93–96.

    Article  PubMed  CAS  Google Scholar 

  26. Leizorovicz, A., Haugh, M., & Boissel, J. P. (1992). Meta-analysis and multiple publication of clinical trial reports. Lancet, 340(8827), 1102–1103.

    Article  PubMed  CAS  Google Scholar 

  27. Montenero, A. S., Bruno, N., Antonelli, A., Mangiameli, D., Barbieri, L., Andrew, P., et al. (2005). Long-term efficacy of cryo catheter ablation for the treatment of atrial flutter: results from a repeat electrophysiologic study. Journal of the American College of Cardiology, 45(4), 573–580.

    Article  PubMed  Google Scholar 

  28. Wang, F., Huang, C. X., Chen, G., Zhang, F., Meng, W. D., & Sun, B. G. (2007). Safety and efficacy of cryothermal and radiofrequency catheter ablation in treatment of typical atrial flutter. Chinese Medical Journal (Engl), 120(11), 1007–1009.

    Google Scholar 

  29. Thornton, A. S., Janse, P., Alings, M., Scholten, M. F., Mekel, J. M., Miltenburg, M., et al. (2008). Acute success and short-term follow-up of catheter ablation of isthmus-dependent atrial flutter; a comparison of 8 mm tip radiofrequency and cryothermy catheters. Journal of Interventional Cardiac Electrophysiology, 21(3), 241–248.

    Article  PubMed  CAS  Google Scholar 

  30. Malmborg, H., Lonnerholm, S., & Lundqvist, C. B. (2009). A prospective randomised comparison of large-tip cryoablation and 8-mm-tip radiofrequency catheter ablation of atrial flutter. Journal of Interventional Cardiac Electrophysiology, 24(2), 127–131.

    Article  PubMed  Google Scholar 

  31. Rodriguez, L. M., Geller, J. C., Tse, H. F., Timmermans, C., Reek, S., Lee, K. L., et al. (2002). Acute results of transvenous cryoablation of supraventricular tachycardia (atrial fibrillation, atrial flutter, Wolff-Parkinson-White syndrome, atrioventricular nodal reentry tachycardia). Journal of Cardiovascular Electrophysiology, 13(11), 1082–1089.

    Article  PubMed  Google Scholar 

  32. Manusama, R., Timmermans, C., Philippens, S., Crijns, H. J., Ayers, G. M., & Rodriguez, L. M. (2004). Single cryothermia applications of less than five minutes produce permanent cavotricuspid isthmus block in humans. Heart Rhythm, 1(5), 594–599.

    Article  PubMed  Google Scholar 

  33. Manusama, R., Timmermans, C., Limon, F., Philippens, S., Crijns, H. J., & Rodriguez, L. M. (2004). Catheter-based cryoablation permanently cures patients with common atrial flutter. Circulation, 109(13), 1636–1639.

    Article  PubMed  Google Scholar 

  34. Daubert, J. P., Hoyt, R. H., John, R., Chinitz, L., Martin, D. T., Fellows, C., et al. (2005). Performance of a new cardiac cryoablation system in the treatment of cavotricuspid valve isthmus-dependent atrial flutter. Pacing and Clinical Electrophysiology, 28(Suppl 1), S142–S145.

    Article  PubMed  Google Scholar 

  35. Montenero, A. S., Bruno, N., Zumbo, F., Antonelli, A., Fiocca, L., Barbieri, L., et al. (2005). Cryothermal ablation treatment of atrial flutter–experience with a new 9 French 8 mm tip catheter. Journal of Interventional Cardiac Electrophysiology, 12(1), 45–54.

    Article  PubMed  Google Scholar 

  36. Kuniss, M., Kurzidim, K., Greiss, H., Berkowitsch, A., Sperzel, J., Hamm, C., et al. (2006). Acute success and persistence of bidirectional conduction block in the cavotricuspid isthmus one month post cryocatheter ablation of common atrial flutter. Pacing and Clinical Electrophysiology, 29(2), 146–152.

    Article  PubMed  Google Scholar 

  37. Hochholzer, W., Schlittenhardt, D., Arentz, T., Stockinger, J., Weber, R., Burkle, G., et al. (2007). Platelet activation and myocardial necrosis in patients undergoing radiofrequency and cryoablation of isthmus-dependent atrial flutter. Europace, 9(7), 490–495.

    Article  PubMed  Google Scholar 

  38. Moreira, W., Timmermans, C., Wellens, H. J., Mizusawa, Y., Perez, D., Philippens, S., et al. (2008). Long term outcome of cavotricuspid isthmus cryoablation for the treatment of common atrial flutter in 180 patients: a single center experience. Journal of Interventional Cardiac Electrophysiology, 21(3), 235–240.

    Article  PubMed  Google Scholar 

  39. Feld, G. K., Daubert, J. P., Weiss, R., Miles, W. M., & Pelkey, W. (2008). Acute and long-term efficacy and safety of catheter cryoablation of the cavotricuspid isthmus for treatment of type 1 atrial flutter. Heart Rhythm, 5(7), 1009–1014.

    Article  PubMed  Google Scholar 

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Disclosures

This work was not funded or sponsored by industry or research grant. Authors had full control of all primary data and agreed to allow the journal to review the data if requested. Drs. Andrew, Montenero, and O'Connor have worked with CryoCath Technologies Inc in the past. There are no current financial disclosures or relationships to declare.

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Authors and Affiliations

  1. ATLAS Medical Research Inc, Edmonton, Alberta, Canada

    Peter Andrew

  2. Yasir Hamad, Harbor Hospital, Baltimore, MD, USA

    Yasir Hamad

  3. Chairman of Cardiology, MultiMedica General Hospital, Via Milanese 300, 20099, Sesto S. Giovanni (Milan), Italy

    Annibale Montenero

  4. 4 The Green, Bromham, Bedfordshire, UK

    Stephen O’Connor

  5. ATLAS Medical Research Inc., Edmonton, Alberta, Canada

    Sandra Jerat

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  1. Peter Andrew
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  2. Yasir Hamad
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  3. Sandra Jerat
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  4. Annibale Montenero
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  5. Stephen O’Connor
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Correspondence to Peter Andrew or Sandra Jerat.

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Andrew, P., Hamad, Y., Jerat, S. et al. Approaching a decade of cryo catheter ablation for type 1 atrial flutter—a meta-analysis and systematic review. J Interv Card Electrophysiol 32, 17–27 (2011). https://doi.org/10.1007/s10840-011-9582-0

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  • DOI: https://doi.org/10.1007/s10840-011-9582-0

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