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

PurposeAdverse left atrial (LA) remodeling is known to be associated with persistent atrial fibrillation (PeAF). The time course and pattern of reversal of LA remodeling following catheter ablation is poorly understood. We aimed to evaluate LA chamber volumes and dimensions, LA conduction velocities, and LA bipolar voltages at baseline and at 2 months after catheter ablation for PeAF.MethodsTwenty-three patients with PeAF underwent detailed LA mapping during fixed rate atrial pacing using the CARTO3 navigation system prior to undergoing pulmonary vein isolation. All patients returned for protocol-mandated repeat electrophysiology study at 2 months, irrespective of symptoms or arrhythmia recurrence, during which all measurements were repeated using an identical mapping protocol. Patients then underwent daily ECG monitoring for 12 months.ResultsNineteen out of twenty-three (83.6%) patients had durable PVI of all veins at repeat electrophysiology study, while 4 (17.4%) patients had late reconnection of a single vein each. In the blinded offline analysis, LA volume at follow-up was significantly lower as compared with baseline (55 ± 14 mL/m2 vs. 65 ± 15 mL/m2, P < 0.001). LA conduction velocities were significantly greater at 2 months (0.90 ± 0.13 m/s vs. 0.78 ± 0.13 m/s, P = 0.01). There was non-uniform regional LA voltage evolution, with a significant increase in bipolar voltages observed on the LA posterior wall (2.18 ± 0.85 mV vs. 1.83 ± 0.49 mV, P = 0.04), but not elsewhere. Individual variables of remodeling were not associated with AF recurrence.ConclusionSignificant structural and electrical reverse remodeling of the LA can be seen as early as 2 months following successful catheter ablation for PeAF.

BackgroundCRAFT was an international, multicentre, randomised controlled trial across 11 sites in the United UK and Switzerland. Given the evidence that pulmonary vein triggers may be responsible for atrial flutter (AFL) as well as atrial fibrillation (AF), we hypothesised that cryoballoon pulmonary vein isolation (PVI) would provide greater symptomatic arrhythmia reduction than cavotricuspid isthmus (CTI) ablation, whilst also reducing the subsequent burden of AF. Twelve-month outcomes were previously reported. In this study, we report the extended outcomes of the CRAFT study to 36 months.MethodsPatients with typical AFL and no evidence of AF were randomised 1:1 to cryoballoon PVI or radiofrequency CTI. All patients received an implantable loop recorder (ILR) for continuous cardiac rhythm monitoring. The primary outcome was time-to-symptomatic arrhythmia recurrence > 30 s. Secondary outcomes included time-to-first-AF episode ≥ 2 min. The composite safety outcome included death, stroke and procedural complications.ResultsA total of 113 patients were randomised to cryoballoon PVI (n = 54) or radiofrequency CTI ablation (n = 59). Ninety-one patients reconsented for extended follow-up beyond 12 months. There was no difference in the primary outcome between arms, with the primary outcome occurring in 12 PVI vs 11 CTI patients (HR 0.97; 95% CI 0.43–2.20; p = 0.994). AF ≥ 2 min was significantly less frequent in the PVI arm, affecting 26 PVI vs 36 CTI patients (HR 0.48; 95% CI 0.29–0.79; p = 0.004). The composite safety outcome occurred in 5 PVI and 6 CTI patients (p = 0.755).ConclusionCryoballoon PVI shows similar efficacy to radiofrequency CTI ablation in reducing symptomatic arrhythmia recurrence in patients presenting with isolated typical AFL but significantly reduces the occurrence of subsequent AF.

Method In this study six nurses from general intensive care units were interviewed. The resulting transcripts were analysed using hermeneutic phenomenology. Findings The findings fall into five categories, feelings, communication, protection, education, and technology. Nurses appear to suffer a degree of cognitive dissonance that both adds to their stress and leads to difficulties in explaining brainstem death to relatives. Conclusion Nurses need more education and support to enable them to overcome cognitive dissonance and so give relatives honest information. Verbal information should be supplemented with a written information leaflet given to all relatives. [Copyright Elsevier Ltd.]

In this study six nurses from general intensive care units were interviewed. The resulting transcripts were analysed using hermeneutic phenomenology. The findings fall into five categories, feelings, communication, protection, education, and technology. Nurses appear to suffer a degree of cognitive dissonance that both adds to their stress and leads to difficulties in explaining brainstem death to relatives. Nurses need more education and support to enable them to overcome cognitive dissonance and so give relatives honest information. Verbal information should be supplemented with a written information leaflet given to all relatives.

PurposeTreatment of typical atrial flutter (AFL) with cavo-tricuspid isthmus (CTI) ablation is associated with a high occurrence rate of new onset atrial fibrillation (AF) during follow-up. There are data to support the addition of pulmonary vein isolation (PVI) to CTI ablation in patients with both AF and AFL, but the role of cryoballoon PVI only, with no CTI ablation, in AFL patients with no prior documentation of AF has not been studied.MethodsCRAFT is an international, prospective, randomised, open with blinded assessment, multicentre superiority study comparing radiofrequency CTI ablation and cryoballoon PVI in patients with typical AFL. Participants with typical AFL are randomised in a 1:1 ratio to either treatment arm, with patients randomised to PVI not receiving CTI ablation. Post-procedural cardiac monitoring is performed using an implantable loop recorder. The primary endpoint is time to first recurrence of sustained symptomatic atrial arrhythmia. Key secondary endpoints include (1) total arrhythmia burden at 12 months, (2) time to first episode of AF lasting ≥ 2 min, (3) time to recurrence of AFL or AT and (4) procedural and fluoroscopy times. The primary safety endpoint is the composite of death, stroke/transient ischaemic attack, cardiac tamponade requiring drainage, atrio-oesophageal fistula, requirement for a permanent pacemaker, serious vascular complications requiring intervention or delaying discharge and persistent phrenic nerve palsy lasting > 24 h.ConclusionThis study compares the outcomes of 2 different approaches to typical AFL—the conventional ‘substrate’-based strategy of radiofrequency CTI ablation versus a novel ‘trigger’-based strategy of cryoballoon PVI.Trial registration(ClinicalTrials.gov ID: NCT03401099)