Results From a Single-Blinded Randomized Study (APPROVAL) Comparing the Impact of Different Ablation Strategies on Long Term Procedure Outcome in Coexistent Atrial Fibrillation and Flutter

Study Questions:

Is pulmonary vein isolation (PVI) necessary in patients with both paroxysmal atrial fibrillation (AF) and right atrial flutter (AFl)?


Three hundred sixty patients (mean age 62 years) with documented paroxysmal AF and AFl were randomly assigned to antral PVI ± cavotricuspid isthmus (CTI) ablation (group 1, n = 182) or only CTI ablation (group 2, n = 178). The patients were blinded to the randomization. Efficacy was assessed with event monitors and 7-day Holter monitors at 3, 6, 9, and 12 months of follow-up. Quality of life was assessed at baseline and 12 months.


In group I, 32% of patients underwent antral PVI and CTI ablation, and 68% underwent only antral PVI. Freedom from AF/AFl off antiarrhythmic drugs at 21 months of follow-up was significantly higher in group 1 (64%) than in group 2 (19%). Among the group 1 patients, efficacy did not differ between patients who did and did not undergo CTI ablation. Quality of life improved to a significantly greater degree in group 1 than in group 2.


In patients with coexistent paroxysmal AF and AFl, PVI with or without CTI ablation is much more likely than CTI ablation by itself to prevent recurrent atrial arrhythmias.


The results of this study are consistent with prior studies showing that AFl is induced by AF much more often than AF is induced by AFl. The one scenario in which CTI ablation can be sufficient to prevent recurrent atrial arrhythmias in patients with a history of AF and AFl is the patient with paroxysmal AF who develops class IC-induced AFl.

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Follow-Up Studies, Quality of Life, Heart Conduction System, Pulmonary Veins, Electrocardiography, Catheter Ablation, Atrial Flutter

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