Impact Of Different Ablation Approaches on Outcome In Coexistent Atrial Fibrillation and Flutter

Specific Aim: This prospective single blinded study aims to compare the influence of two different catheter ablation strategies, on long-term ablation outcome in terms of AF recurrence and quality of life (QoL) in patients presenting with coexistent AF and AFL. The two strategies to be evaluated are 1) the ablation of paroxysmal atrial fibrillation (PAF) with or without flutter (AFL) ablation (AF ± AFL) versus 2) AFL ablation alone.

Hypothesis: Ablation of AF ± AFL results in better long-term procedure outcome than AFL-ablation alone in patients with a documented history of AF and AFL.

Background: Coexistence of AF and AFL is commonly encountered in clinical practice. Patients with these arrhythmias experience symptoms such as palpitation which is often described as a sudden irregular fluttering sensation in the chest, dyspnea, fatigue, dizziness and fainting attacks. These symptoms make the patients anxious and tired and seriously compromise their QoL (1).

Radiofrequency catheter ablation (RFCA) has emerged as the best therapeutic option in drug-refractory AF cases and often used as a first-line therapy in AFL (2). Several studies have demonstrated significant improvement in QoL following catheter ablation (CA) when patients have either AF or AFL (3-9). However, very little is known about the impact of CA on QoL in patients presenting with coexistent AF and AFL.

No standard treatment guidelines exist for coexistent AF and AFL. Determining the best ablative approach for this type of patient remains a challenge. Roithinger et al (10) postulated that the mechanism of AFL in patients presenting with both arrhythmias could be organization of AF to AFL. However, it is not always possible to determine which is the predominate arrhythmia. In some cases, AFL ablation can eliminate AF and AFL, and is a less extensive procedure than AF ablation. As the two arrhythmias are inter-twined, it is possible that AFL ablation alone may be sufficient to cure both arrhythmias. Should an AF ablation be required at a later date, there is no supportive data suggesting that the second procedure is associated with additional complications. Therefore, performing an AFL ablation alone does not expose the patient to any unwarranted risk. (11) Several published studies have reported on a variety of ablation strategies for different types of AF, to include paroxysmal, persistent and long standing persistent, with variable results on AF recurrence. (12-16) Compared to previous studies, the scope of the APPROVAL study is narrowed to include patients with AF falling into the 'paroxysmal' category.