Long-Term Outcomes of Cryoballoon Pulmonary Vein Isolation Freeze Using a Modified ICE-T Protocol With a Double 120 s Applications (ICE-T 2 × 2).

Pulmonary vein isolation (PVI) by cryoballoon ablation (CBA) is considered an effective primary strategy for early persistent atrial fibrillation (AF). However, data regarding CBA for long-standing persistent AF (PeAF) are limited. We evaluated the efficacy and safety of CBA for long-standing PeAF compared to PeAF. The study included 1484 patients with non-paroxysmal AF from Korean CBA registry data with follow-up of > 12 months after de novo CBA. The primary outcome was recurrence of atrial tachyarrhythmias (ATs) of ≥ 30-s after a 3-month blanking period. A total of 367 PeAF (25%) and 1117 long-standing PeAF (75.3%) patients (mean age 61.9 ± 9.6 years, 80% men) underwent de novo CBA. Compared to patients with PeAF, patients with long-standing PeAF had more heart failure, previous stroke or transient ischemic attack, chronic kidney disease, higher CHA2DS2-VASc score, and larger left atrium (LA). During a mean follow-up period of 15.1 ± 10.9 months, ATs recurrence occurred in 41.4% of PeAF and 40.1% of long-standing PeAF. Multivariate analysis showed that female gender (hazard ratio [HR]: 1.31, p = 0.01), larger LA ≥ 45 mm (HR: 1.53, p < .001) and LA volume index ≥ 51 mL/m2 (HR: 1.77, p < 0.001), and longer AF duration ≥ 5 years (HR: 1. 33, p = .003) were associated with ATs recurrence. After propensity score matching, larger LA was an independent factor for ATs recurrence. During a long-term follow-up period after index CBA in patients with non-paroxysmal AF, ATs recurrence rate was similar between PeAF and long-standing PeAF. CBA might be an effective strategy as an initial rhythm control therapy regardless of AF type.

Comparison of Extended Cryoballoon, Standard Cryoballoon, and Radiofrequency Catheter Ablation in Patients With Persistent AF.

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Background Catheter ablation for atrial fibrillation (AF) in octogenarians poses a challenge due to comorbidities, frailty, and suspected higher complication rates. Data regarding the outcome of catheter ablation in this population is scarce. Purpose Due to the projected increase of octogenarians presenting with AF in the future, we investigated the outcome of catheter ablation in this patient population. Methods We retrospectively analysed octogenarians with symptomatic AF undergoing catheter ablation in a single centre, including first and re-ablation procedures. Catheter ablation involved pulmonary vein isolation (PVI) using radiofrequency (RF), cryoballoon (CB) and pulsed field ablation (PFA) as energy sources and also atrial tachycardia (AT) ablation including linear lesions and/or ablation of complex fractionated atrial electrograms (CFAE). Follow-up (FU) was obtained to assess arrhythmia-free survival after a 90-day blanking period, recurrences after the blanking period, management of recurrences, rhythm at FU, use of antiarrhythmic drugs (AADs) and improvement in symptoms (EHRA symptom scale). Results A total of 126 patients (mean age 82.2 ± 1.9 years, paroxysmal AF n=48, persistent AF n=78, mean CHA2DS2-VASc-Score 4.2 ± 1.5) were included. 57.1% (n=72/126) underwent an index procedure {47.2% (n=34/72) RF PVI, 37.5% (n=27/72) CB PVI, 4.2% (n=3/72) PFA PVI and 11.1% (n=8/72) PVI + AT ablation}. 42.9% (n=54/126) received repeat procedures {20.4% (n=11/54) re-PVI, 42.6% (n=23/54) re-PVI + AT ablation, 37% (n=20/54) AT ablation}. FU of 108 patients after 15.4 ± 3.6 months revealed arrhythmia-free survival after the blanking period in 64.8% (n=70/108). Recurrence after the blanking period was seen in 35.2% (n=38/108). No significant difference in recurrences was shown between index and repeat procedures (32.3%, n=20/62 after index procedures and 36.7%, n=18/49 after repeat procedures, p =0.97). Management of recurrence involved repeat ablation (47%, n=18/38), AADs (16%, n=6/38), cardioversion (21%, n=8/38), pacemaker-implantation/AV-node ablation (5%, n=2/38) and pharmacological rate control (11%, n=4/38). At FU, 88.9% (n=96/108) of patients were in sinus rhythm with 21.3% (n=23/108) receiving AADs, 7.4% (n=8/108) were in AF, 0.9% (n=1/108) in AT and 2.8% (n=3/108) pacemaker-dependant. Symptoms were significantly improved at FU (mean EHRA score at FU= 1.2 ± 0.5, before ablation= 2.4 ± 0.5, p &amp;lt;0.0001). Conclusion Catheter ablation for AF in octogenarians is effective in maintaining sinus rhythm and controlling AF-related symptoms. Longer term success and impact on prognosis in this patient population is unknown and should be investigated further.

Wide-area antral pulmonary vein and posterior wall isolation by way of segmental nonocclusive applications using a novel radiofrequency ablation balloon

Introduction: Cryoballoon pulmonary vein isolation (PVI) has emerged as an alternative to radiofrequency PVI for the treatment of paroxysmal atrial fibrillation (AF). The optimal ablation strategy for patients with persistent AF is unclear, as data on Cryoballoon PVI alone are limited. Methods: We analyzed a prospective registry of consecutive patients with persistent AF who underwent Cryoballoon PVI at a single center between 2011 and 2014. Patients were assessed for AF recurrence (including any atrial arrhythmia) after a 3 month blanking period at 6 months, 1 year, 2 years, and as needed for symptoms post PVI. Recurrence was based on typical symptoms or ECG/ event monitor evidence of AF. Kaplan-Meier analysis was used to estimate AF-free survival. Results: The 69 patients who underwent Cryoballoon PVI were aged 59 ± 8 years, 86% male, 54% HTN, had a CHADS2-VASC score 1.6 ± 1.2, and had a LA dimension 4.5 ± 0.6 cm. The AF recurrence-free rate at 1-year post-procedure was 59%. Overall, AF-free survival was 50% at the mean follow-up of 607 days. In comparing patients with persistent AF duration &lt;1 year vs. &gt;1 year, there was a trend toward greater AF recurrence-free rates in the &lt;1 year group (66% vs 55%, p=0.09) Conclusions: Cryoballoon PVI appears to be an effective initial strategy in treating persistent AF, with an AF recurrence-free rate of 59% at 1 year.

Individualized cryoballoon energy pulmonary vein isolation guided by real-time pulmonary vein recordings, the randomized ICE-T trial

Cryoballoon pulmonary vein isolation has become an established treatment for atrial fibrillation (AF). However, data on long-term outcomes beyond 5 years are scarce. This prospective analysis aimed to evaluate the long-term outcome after cryoballoon pulmonary vein isolation. Data from consecutive patients treated with cryoballoon pulmonary vein isolation for symptomatic AF between 2012 and 2018 in 13 institutions were analyzed. Patients with ≥5-year follow-up after the index procedure were included. Arrhythmia recurrence was defined as AF or atrial tachycardia lasting >30 seconds beyond a 3-month blanking period. A total of 1330 patients were enrolled (28.4% female patients, mean age was 60.1±10.5 years). Patients with paroxysmal AF accounted for 73.1%; the median history of AF was 36.0 (13.0-75.0) months. The rate of AF/atrial tachycardia recurrences progressively increased over time (event rate: 52.5% [49.4%-55.8%] at 8-year follow-up). A low incidence of progression to permanent AF was seen in the entire cohort (7.0%). Importantly, 15.7% of patients underwent a redo ablation for AF during follow-up; in 45.9% of these cases, all PVs were isolated at the redo procedure, with a median number of PVs isolated after the index procedure being 3 (1-4) veins. Independent predictors of arrhythmia recurrences were AF type (persistent AF: hazard ratio, 1.36 [95% CI, 1.14-1.62]; P<0.001) and chronic kidney disease (hazard ratio, 1.77 [95% CI, 1.12-2.81]; P=0.016) in multivariate analysis. Cryoballoon pulmonary vein isolation as the index procedure for AF ablation resulted in a favorable long-term outcome in patients with symptomatic AF, with limited progression towards permanent AF during follow-up. Persistent AF was the strongest predictor of recurrences at long-term follow-up.

Ten-year ablation outcomes of patients with paroxysmal atrial fibrillation undergoing pulmonary vein isolation

Non-inducibility of AF post electrophysiologically based PV isolation predicts freedom from AF

Cryoballoon ablation for persistent atrial fibrillation – Large single-center experience

Aim. To study the impact and safety of cryoballoon ablation of the pulmonary vein (PV), supplemented by isolation of the superior vena cava in patients with persistent atrial fibrillation (AF).Methods. The study is single-center, randomized, prospective. The total number of patients was 40. All of them underwent cryoballoon isolation of the PV for persistent AF. The patients were then divided into two groups: the first group included patients who underwent the standard procedure, and the second group included patients with the standard procedure supplemented by isolation of the superior vena cava. Patients in both groups had similar anatomical and clinical-anamnestic parameters. The duration of the surgical intervention was not statistically different.Results. The average follow-up period was 354±19 days. In the group of classical cryoballoon PV isolation, after 12 months of observation without antiarrhythmic therapy, sinus rhythm was maintained in 40% of patients (8 people), in the group of extended cryoballoon PV isolation - in the same number of patients (40%, P=1). In the PV isolation group, persistent phrenic nerve palsy was observed in no patients, and in the extended ablation group, in eight patients (40%, P=0.0016). At the end of the observation, no remote complications were registered.Conclusions. In patients with persistent AF, cryoballoon PV isolation supplemented by superior vena cava isolation is a less safe technique than standard cryoballoon pulmonary vein isolation, with comparable efficacy.

Reflections on reconduction after pulmonary vein isolation

Freedom from recurrences of atrial tachyarrhythmia (ATA) is suboptimal after pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (PsAF). This sub-analysis from the Cryo Global Registry sought to investigate predictors of ablation success after PVI using cryoballoon ablation (CBA) for PsAF. ATA recurrence was defined as ≥ 30 s recurrence of atrial fibrillation, atrial flutter or atrial tachycardia after a 90-day blanking period and through 12-months. Univariate and multivariable Cox regression analysis (with ATA recurrence as an endpoint) was performed to identify CBA responders. PsAF patients (N = 882) were on average 63.9 ± 11.3 years old (69.2% male), and freedom from ATA recurrence was 79.7% (76.8%-82.2%). Longer elapsed time from PsAF diagnosis to ablation (hazard ratio [HR] 1.07 (95% confidence interval [CI]: 1.03-1.11); p = 0.002) and a larger number of previously failed antiarrhythmic drugs (HR 1.39 (95% CI: 1.13-1.70); p < 0.002) were shown to be independent predictors of ATA recurrence in a multivariate model which included 703 evaluated patients. These real-world results provide important insights to guide referral of PsAF patients, including the benefits of earlier treatment via CBA.

Previous studies have given conflicting data regarding the long-term adjunctive efficacy of linear lesions (LLs) on top of pulmonary vein isolation (PVI) as an ablation strategy in patients with atrial fibrillation (AF). The aim of this meta-analysis was to provide a detailed analysis of the available randomized controlled trials (RCTs) regarding the efficacy of LL following PVI in AF patients. Current databases were searched until October 2015. The primary outcome end point of the meta-analysis was recurrence of any symptomatic or documented episode of AF or atrial tachycardia after a single ablation procedure with or without the use of antiarrhythmic drugs. Ten RCTs with a total of 1,446 patients were included in the meta-analysis. The pooled analysis of five trials concerning persistent AF (PeAF) patients (400 in PVI plus LL group and 182 in PVI alone group) suggested that the addition of LL following PVI does not lead to a significant reduction in recurrent atrial tachyarrhythmias compared with PVI alone (relative ratio [RR] = 0.73, 95% confidence interval [CI]: 0.44-1.21, P = 0.22). Similarly, there was no incremental benefit of additional LL in long-term outcomes in paroxysmal AF (PAF) patients (RR = 0.85, 95% CI: 0.68-1.05, P = 0.13). Pooling the results of all eligible trials suggested that PVI plus LL compared with PVI alone significantly increased radiofrequency time (P = 0.0002), fluoroscopy time (P < 0.00001), and procedure time (P < 0.0001). This meta-analysis suggests that LL following PVI does not provide additional benefit to sinus rhythm maintenance in patients with PeAF and PAF.