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Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter
  1. Dhiraj Gupta1,2,3,
  2. Wern Yew Ding1,2,3,
  3. Peter Calvert1,2,3,
  4. Emmanuel Williams1,2,3,
  5. Moloy Das4,
  6. Lilith Tovmassian1,
  7. Muzahir H Tayebjee5,
  8. Guy Haywood6,
  9. Claire A Martin7,
  10. Kim Rajappan8,
  11. Matthew G D Bates9,
  12. Ian Peter Temple10,
  13. Tobias Reichlin11,
  14. Zhong Chen12,
  15. Richard N Balasubramaniam13,
  16. Christina Ronayne1,
  17. Nichola Clarkson1,
  18. Maureen Morgan1,
  19. Janet Barton1,
  20. Ian Kemp1,
  21. Saagar Mahida1,
  22. Christian Sticherling14
  1. 1 Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
  2. 2 Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
  3. 3 Liverpool Centre for Cardiovascular Science, Liverpool, UK
  4. 4 Newcastle Upon Tyne Hospital NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
  5. 5 Department of Cardiology, Leeds Teaching Hospital NHS Foundation Trust, Leeds, UK
  6. 6 Department of Cardiology, University Hospitals Plymouth NHS Foundation Trust, Plymouth, UK
  7. 7 Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
  8. 8 Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  9. 9 Department of Cardiology, South Tees Hospitals NHS Foundation Trust, James Cook University Hospital, Middlesbrough, UK
  10. 10 Department of Cardiology, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
  11. 11 Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
  12. 12 Department of Cardiology, Ashford and St Peter’s Hospital NHS Foundation Trust, Surrey, UK
  13. 13 Department of Cardiology, Royal Bournemouth and Christchurch Hospital NHS Foundation Trust, Bournemouth, UK
  14. 14 Department of Cardiology, University Hospital Basel, Basel, Switzerland
  1. Correspondence to Dr Dhiraj Gupta, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool L14 3PE, UK; dhiraj.gupta{at}


Objective We aimed to compare cryoballoon pulmonary vein isolation (PVI) with standard radiofrequency cavotricuspid isthmus (CTI) ablation as first-line treatment for typical atrial flutter (AFL).

Methods Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter was an international, multicentre, open with blinded assessment trial. Patients with CTI-dependent AFL and no documented atrial fibrillation (AF) were randomised to either cryoballoon PVI alone or radiofrequency CTI ablation. Primary efficacy outcome was time to first recurrence of sustained (>30 s) symptomatic atrial arrhythmia (AF/AFL/atrial tachycardia) at 12 months as assessed by continuous monitoring with an implantable loop recorder. Primary safety outcome was a composite of death, stroke, tamponade requiring drainage, atrio-oesophageal fistula, pacemaker implantation, serious vascular complications or persistent phrenic nerve palsy.

Results Trial recruitment was halted at 113 of the target 130 patients because of the SARS-CoV-2 pandemic (PVI, n=59; CTI ablation, n=54). Median age was 66 (IQR 61–71) years, with 98 (86.7%) men. At 12 months, the primary outcome occurred in 11 (18.6%) patients in the PVI group and 9 (16.7%) patients in the CTI group. There was no significant difference in the primary efficacy outcome between the groups (HR 1.11, 95% CI 0.46 to 2.67). AFL recurred in six (10.2%) patients in the PVI arm and one (1.9%) patient in the CTI arm (p=0.116). Time to occurrence of AF of ≥2 min was significantly reduced with cryoballoon PVI (HR 0.46, 95% CI 0.25 to 0.85). The composite safety outcome occurred in four patients in the PVI arm and three patients in the CTI arm (p=1.000).

Conclusion Cryoballoon PVI as first-line treatment for AFL is equally effective compared with standard CTI ablation for preventing recurrence of atrial arrhythmia and better at preventing new-onset AF.

Trial registration number NCT03401099.

  • Atrial Fibrillation
  • Arrhythmias, Cardiac
  • Atrial Flutter
  • Ablation Techniques
  • Catheter Ablation

Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request from the corresponding author.

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Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request from the corresponding author.

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  • Contributors DG contributed to the design of the study, interpreted the data, drafted the manuscript and is the guarantor; WYD contributed to the design of the study, analysed and interpreted the data, and drafted the manuscript; PC analysed and interpreted the data and drafted the manuscript; EW contributed to the design of the study; MD, LT, MHT, GH, CAM, KR, MGDB, IPT, TR, ZC, RNB, CR, NC, MM, JB, IK, SM and CS revised the manuscript critically for important intellectual content.

  • Funding CRAFT is funded by Medtronic International Trading Sarl as part of an investigator-sponsored study programme (grant number AF-3908).

  • Competing interests DG was a speaker for Bayer, BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, Medtronic, Biosense Webster and Boston Scientific and a proctor for Abbott, and received research grants from Medtronic, Biosense Webster and Boston Scientific. MD received fellowship funding from Biosense and speaker fees from Boston-Scientific. CAM received speaker fees and research grants from BSCI and Medtronic and speaker fees from Biosense Webster for work outside the submitted study, TR received research grants from the Goldschmidt-Jacobson Foundation, the Swiss National Science Foundation, the Swiss Heart Foundation, the European Union (Eurostars 9799–ALVALE), the Professor Max Cloëtta Foundation, the Cardiovascular Research Foundation Basel, the University of Basel and the University Hospital Basel; speaker/consulting honoraria or travel support from Abbott/SJM, Astra Zeneca, Brahms, Bayer, Biosense-Webster, Biotronik, Boston-Scientific, Daiichi Sankyo, Medtronic, Pfizer-BMS and Roche; and support for his institution’s fellowship programme from Abbott/SJM, Biosense-Webster, Biotronik, Boston-Scientific and Medtronic. CS reported grants and lecture fees from Biosense Webster and Medtronic and served as a proctor for Biosense Webster and Medtronic. Other authors have no relevant disclosures to declare.

  • Patient and public involvement Patients and/or the public were involved in the design, conduct, reporting or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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