Efficacy of two-stage approach for interventional treatment of coexistent atrial fibrillation and typical atrial flutter for sinus rhythm maintenance in long-term: a prospective controlled clinical trial

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Abstract

Background: Atrial fibrillation (AF) and coexistent typical atrial flutter (AFL) interventional treatment strategy remains unresolved in cardiology and cardiovascular surgery. Results of this approach remain suboptimal. There are several approaches to the interventional treatment of patients with coexistent AF and AFL: simultaneous pulmonary vein isolation (PVI) and cavotricuspid isthmus (CTI) radiofrequency catheter ablation (RFCA), PVI or CTI RFCA only and two-stage approach. To our knowledge, cumulative efficacy of two-stage approach has not been previously reported.

The aim. This study aimed to evaluate the efficacy of two-stage approach for interventional treatment of coexistent AF and AFL for sinus rhythm maintenance in long-term.

Methods: Patients (pts) (n=34) with AF and AFL aged 41–82 years (11 women) were divided into two groups (1:1): «One-stage Approach» (group 1; n=17): PVI+СTI RFСA and «Two-stage approach» (group 2; n=17): first stage — CTI RFCA (group 2.1); second stage — PVI in case of AF recurrence after RFCA (group 2.2). Primary endpoint (PEP) was defined as any recurrent atrial tachyarrhythmia at the end of follow-up; group 2 events have been considered after PVI. Secondary endpoint (SEP) — recurrent any atrial tachyarrhythmia in groups 1 and 2 after CTI RFCA in group 2. PEP and SEP were evaluated at the end of the «blind period» (3 months after procedure).

Results: Registered recurrent atrial tachyarrhythmia in pts who reached PEP or SEP was AF. AFL has not been detected in any cases. PEP was noted in 8 (47.06%) pts in group 1 and 1 (5.88%) pts in group 2. Further, SEP was observed in 3 pts (17.65%) in group 1 and in 4 (23.53%) pts in group 2 (p=0.671). The probability of long-term maintenance of sinus rhythm was significantly higher in «Two-stage approach» than in «One-stage approach» (94.12% and 52.94%, respectively, p=0.001). Significant differences in procedure length and fluoroscopy time have been found. Those were longer in group 1 compared to group 2.1 (p <0.001) and in group 2.2 compared to group 2.1 (procedure duration — p <0.001; fluoroscopy time — p=0.013). No differences were noted in length of procedure and fluoroscopy time between groups 1 and 2.2 (p=0.374 and p=0.028, respectively).

Conclusion: The «two-stage approach» for interventional treatment of coexistent AF and AFL results in better long-term arrhythmia-free survival than «one-stage approach» (94.12% and 52.94%, respectively, p=0.001). CTI RFCA alone in pts with coexistent AF and AFL cause 23.53% AF recurrence rate and associated with shorter procedure duration and fluoroscopy time compared to simultaneous PVI and CTI RFCA (p <0.001).

About the authors

Igor A. Khamnagadaev

Endocrinology Research Centre; The Russian National Research Medical University named after N.I. Pirogov

Email: i@khamnagadaev.ru
ORCID iD: 0000-0002-9247-4523
SPIN-code: 6338-4990

MD, PhD

Russian Federation, Moscow; Moscow

Igor A. Kovalev

The Russian National Research Medical University named after N.I. Pirogov

Email: igor.kovalev64@mail.ru
ORCID iD: 0000-0001-8195-5682
SPIN-code: 5024-6323

Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Irina A. Bulavina

Moscow City Clinical Hospital in honor of V.M. Buyanov

Author for correspondence.
Email: doctoroirb@yandex.ru
ORCID iD: 0000-0002-6267-3724
SPIN-code: 1275-2773
Russian Federation, Moscow

Mikhail L. Kokov

Russian State Agrarian University — Moscow Timiryazev Agricultural Academy

Email: mikhailkokov@gmail.com
ORCID iD: 0000-0003-4766-5213
Russian Federation, Moscow

Aleksandr S. Zotov

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies

Email: zotov.alex.az@gmail.com
ORCID iD: 0000-0003-0494-0211
SPIN-code: 9315-6570

MD, PhD

Russian Federation, Moscow

Aleksandr V. Troitskiy

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies

Email: dr.troitskiy@gmail.com
ORCID iD: 0000-0003-2143-8696
SPIN-code: 2670-6662

Dr. Sci. (Med.)

Russian Federation, Moscow

Igor I. Khamnagadaev

Belgorod State National Research University

Email: khamnagadaev@edu.bsu.ru
ORCID iD: 0000-0001-8541-0364
SPIN-code: 6883-5175

Dr. Sci. (Med.), Professor

Russian Federation, Belgorod

Maria A. Shkolnikova

The Russian National Research Medical University named after N.I. Pirogov

Email: arrithmolog@gmail.com
ORCID iD: 0000-0001-7115-0186
SPIN-code: 9051-7107

Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Leonid S. Kokov

Sklifosovsky Research Institute of Emergency Medicine; Moscow State University of Medicine and Dentistry named after A.I. Evdokimov

Email: lskokov@mail.ru
ORCID iD: 0000-0002-3167-3692
SPIN-code: 1655-5794

д.м.н., профессор, академик РАН

Russian Federation, Moscow; Moscow

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Supplementary files

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2. Fig. 1. Study design.

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3. Fig. 2. Long-term sinus rhythm maintenance comparative assessment in groups 1 (n=17) and 2 (n=17): the probability AF recurrence in “One-stage approach” (PVI+CTI RFCA during the one procedure) is significantly higher than in “Two-stage approach” (First stage — CTI RFCA; Second stage — PVI in AF recurrence patients).

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4. Fig. 3. Comparative assessment of the procedure duration in groups: p1–2 <0,001; p1–3=0,374; p2–3 <0,001 (n=34).

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5. Fig. 4. Fluoroscopy time comparative assessment in groups: p1–2 <0,001; p1–3=0,028; p2–3=0,013 (n=34).

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6. Рис. 2. Сравнительная оценка длительного удержания синусового ритма в группах 1 (n=17) и 2 (n=17): вероятность рецидива ФП статистически значимо выше при «Одноэтапном подходе» (ИЛВ+РЧА КТП во время одной операции) по сравнению с «Двухэтапным подходом» (первый этап — РЧА КТП, второй этап — ИЛВ в случае рецидива ФП).

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7. Рис. 1. Дизайн исследования.

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8. Рис. 3. Сравнительная оценка продолжительности операции в исследуемых группах: p1–2 <0,001; p1–3=0,374; p2–3 <0,001 (n=34).

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9. Рис. 4. Сравнительная оценка времени рентгеноскопии в исследуемых группах: p1–2 <0,001; p1–3=0,028; p2–3=0,013 (n=34).

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