Repeat procedures for recurrent persistent atrial fibrillation: A propensity-matched score comparison between left atrial linear ablation with radiofrequency and posterior wall isolation with the cryoballoon

Lesion Transmurality and Continuity of Non-Occlusive Cryoballoon Ablation on Canine Ventricle

BACKGROUND

Our understanding of lesion transmurality and continuity of non-occlusive cryoballoon ablation (NOCA) is limited. In the present study, lesion dimensions under different conditions during NOCA were assessed.

METHODS

Simulated NOCA was performed on freshly harvested canine left ventricular myocardial using the cryoballoon. We conducted experiments to evaluate the effects of (1) flow rate (0, 1, and 1.5 L/min) and freezing time (120, 150, and 180 ) on lesion dimensions during segmental NOCA and (2) overlapping manners between two sequential cryoablations (overlaps of half and two-thirds the balloon area) on lesion continuity during linear NOCA. Lesion formation was assessed after 3-5 h using tetrazolium chloride staining.

RESULTS

(1) Experiments of segmental NOCA No differences were observed in maximal lesion depths among different flow rates (0, 1, and 1.5 L/min) across cryoballoon. For ablation duration, 120-s cryotherapy was able to penetrate to a maximal lesion depth of 6.45 ± 0.80 mm, significantly smaller than those for 150 and 180-s (p < 0.001). (2) Experiments of linear NOCA: Maximal lesion depths of 2 × 120-s linear NOCA were similar between two-thirds and half-size overlaps (p = 0.192). However, non-transmural lesions were more frequently observed in half-size than two-thirds overlap (56.3% vs. 6.3%, p = 0.002).

CONCLUSIONS

When performing NOCA, lesion depths did not vary significantly with convective flow around the CB. A 120-s cryoapplication seemed to yield enough lesion depth and longer cryotherapy should be applied cautiously at a place in close anatomical contact with the esophagus. Additionally, a series of sequential applications in a half-size overlapping manner might lead to non-transmural lesions in the ablation line.

Cryoballoon Ablation With the POLARx FIT or the Arctic Front Advance Pro for Paroxysmal Atrial Fibrillation: A Health Economic Analysis

Background: Pulmonary vein isolation (PVI) is the main ablation strategy for the treatment of paroxysmal atrial fibrillation. Different technologies are available for PVI, including various cryoballoon catheters (CB-A). Compared with the Arctic Front Advance Pro™, the novel POLARx FIT™ CB-A might reduce costs for atrial fibrillation ablation. Objective: The aim of this study is to perform a health economic evaluation of two cryoballoon systems for PVI procedures. Methods: All patients undergoing their first PVI procedure with POLARx FIT™ CB-A or the Arctic Front Advance Pro™ CB-A were prospectively enrolled. The health economic analysis was performed on the index hospitalization and procedure. The primary safety endpoint included procedure-related adverse events within the index hospitalization. A decision tree model was built to estimate downstream costs. Results: A total of 80 patients with paroxysmal atrial fibrillation undergoing PVI were analyzed, with 40 patients in each arm. Compared with the Arctic Front Advance Pro™ CB-A, POLARx FIT™ CB-A showed a lower procedure time, left-atrium dwell time, and fluoroscopy time. The complication rate was low (6.3%) and included 3 reversible phrenic nerve palsies in the POLARx FIT™ CB-A group vs 2 in the Arctic Front Advance Pro™ CB-A group. Compared with the Arctic Front Advance Pro, the POLARx FIT™ CB-A was associated with lower procedural costs (€2069.7 ± €165.2 vs €2239.5 ±  €366.0; P =.009). Conclusion: The POLARx FIT™ CB-A was associated with a shorter procedure time, translating into lower procedural costs, compared with the Arctic Front Advance Pro. Complications were rare and comparable between the two technologies.

Pentaspline catheter or cryoballoon for pulmonary vein plus posterior wall isolation in persistent atrial fibrillation: 1-Year outcomes

BACKGROUND

Left atrial posterior wall isolation (LAPWI) plus pulmonary vein isolation (PVI) can be performed with radiofrequency ablation, cryoballoon ablation (CB-A), or, recently, pulsed field ablation (PFA).

OBJECTIVE

The aims of this study were to evaluate efficacy and safety of the pentaspline PFA catheter for PVI + LAPWI in patients with persistent AF undergoing an index ablation procedure and to compare 1-year outcomes of PVI + LAPWI with PFA vs CB-A.

METHODS

All consecutive patients undergoing an index ablation for persistent atrial fibrillation (AF) at Universitair Ziekenhuis Brussel, Belgium, between 2021 and 2023 were retrospectively screened. Inclusion criteria were persistent AF diagnosis following current guidelines, first AF ablation procedure with PVI + LAPWI using the CB-A or the pentaspline PFA catheter, and 1-year follow-up completed.

RESULTS

A total of 160 patients were included (80 with CB-A and 80 with the pentaspline PFA catheter). PVI + LAPWI was performed with success in 160 (100%) patients, and isolation was confirmed at postprocedure high-density mapping in all. Compared with CB-A, PFA was associated with shorter skin-to-skin procedure time, shorter left atrium dwell time, and shorter fluoroscopy time. At survival analysis, freedom from recurrent atrial tachyarrhythmias at 1-year follow-up was similar between the CB-A and PFA groups (76.2% vs 78.8%; log-rank P = .63).

CONCLUSION

In patients with persistent AF undergoing an index catheter ablation, the pentaspline PFA catheter is safe and effective for PVI + LAPWI. Outcomes after pentaspline PFA catheter ablation at 1 year are favorable and similar to those with the CB-A catheter.

Coronary artery disease in atrial fibrillation ablation: impact on arrhythmic outcomes

AIMS

Catheter ablation (CA) is an established treatment for atrial fibrillation (AF). A computed tomography (CT) may be performed before ablation to evaluate the anatomy of pulmonary veins. The aim of this study is to investigate the prevalence of patients with coronary artery disease (CAD) detected by cardiac CT scan pre-ablation and to evaluate the impact of CAD and revascularization on outcomes after AF ablation.

METHODS AND RESULTS

All consecutive patients with AF diagnosis, hospitalized at Universitair Ziekenhuis Brussel, Belgium, between 2015 and 2019, were prospectively screened for enrolment in the study. Inclusion criteria were (i) AF diagnosis, (ii) first procedure of AF ablation with cryoballoon CA, and (iii) contrast CT scan performed pre-ablation. A total of 576 consecutive patients were prospectively included and analysed in this study. At CT scan, 122 patients (21.2%) were diagnosed with CAD, of whom 41 patients (7.1%) with critical CAD. At survival analysis, critical CAD at CT scan was a predictor of atrial tachyarrhythmia (AT) recurrence during the follow-up, only in Cox univariate analysis [hazard ratio (HR) = 1.79] but was not an independent predictor in Cox multivariate analysis. At Cox multivariate analysis, independent predictors of AT recurrence were as follows: persistent AF (HR = 2.93) and left atrium volume index (HR = 1.04).

CONCLUSION

In patients undergoing CT scan before AF ablation, critical CAD was diagnosed in 7.1% of patients. Coronary artery disease and revascularization were not independent predictors of recurrence; thus, in this patient population, AF ablation should not be denied and can be performed together with CAD treatment.

Hybrid atrial fibrillation ablation: long-term outcomes from a single-centre 10-year experience

AIMS

Hybrid atrial fibrillation (AF) ablation is a promising approach in non-paroxysmal AF. The aim of this study is to assess the long-term outcomes of hybrid ablation in a large cohort of patients after both an initial and as a redo procedure.

METHODS AND RESULTS

All consecutive patients undergoing hybrid AF ablation at UZ Brussel from 2010 to 2020 were retrospectively evaluated. Hybrid AF ablation was performed in a one-step procedure: (i) thoracoscopic ablation followed by (ii) endocardial mapping and eventual ablation. All patients received PVI and posterior wall isolation. Additional lesions were performed based on clinical indication and physician judgement. Primary endpoint was freedom from atrial tachyarrhythmias (ATas). A total of 120 consecutive patients were included, 85 patients (70.8%) underwent hybrid AF ablation as first procedure (non-paroxysmal AF 100%), 20 patients (16.7%) as second procedure (non-paroxysmal AF 30%), and 15 patients (12.5%) as third procedure (non-paroxysmal AF 33.3%). After a mean follow-up of 62.3 months ± 20.3, a total of 63 patients (52.5%) experienced ATas recurrence. Complications occurred in 12.5% of patients. There was no difference in ATas between patients undergoing hybrid as first vs. redo procedure (P = 0.53). Left atrial volume index and recurrence during blanking period were independent predictors of ATas recurrence.

CONCLUSION

In a large cohort of patients undergoing hybrid AF ablation, the survival from ATas recurrence was 47.5% at ≈5 years follow-up. There was no difference in clinical outcomes between patients undergoing hybrid AF ablation as first procedure or as a redo.

Repeat ablation strategy for recurrent persistent atrial fibrillation: A propensity-matched score comparison between "2C3L" and "extensive ablation" approach

BACKGROUND

Debates exist in the repeat ablation strategy for patients with recurrence presenting as persistent atrial fibrillation (AF) after initial persistent AF ablation.

OBJECTIVE

To compare the outcome between the "2C3L" and "extensive ablation" approach in patients undergoing repeat procedures for recurrent persistent AF.

METHODS

Propensity-score matching was performed in 196 patients with AF recurrence undergoing repeat ablation, and 79 patients treated with "2C3L" strategy were matched to 79 patients treated with "extensive ablation" strategy. The "2C3L" approach included pulmonary vein isolation, mitral isthmus, left atrial roof, and cavotricuspid isthmus ablation, while the "extensive ablation" strategy included extensive ablation of a variety of other targets aiming to terminate the AF. The primary outcome was freedom from any atrial tachyarrhythmia after 24-h ambulatory monitoring follow-up for 12 months.

RESULTS

No statistically significant difference was found between the primary outcome between the "2C3L" and the "extensive ablation" group [70.9% vs. 69.6%, p = .862; 95% confidence interval (CI) -12.8 to 15.3], although the "extensive ablation" group had a significantly high proportion of AF termination (19.0% for "2C3L" vs. 41.8% for "extensive ablation" group, p = .002; 95% CI 8.5-35.9). And AF termination was not related to the primary outcome in multifactorial regression. At 40 ± 22 months after the repeat procedure, the primary outcome was also comparable (57.0 % for "2C3L" vs. 48.1% for "extensive ablation" group, p = .265; 95% CI -6.6 to 23.7).

CONCLUSION

The outcome between the "2C3L" and "extensive ablation" approaches was comparable in patients undergoing repeat procedures for recurrent persistent AF.

Atrial Fibrillation Global Changes after Pulmonary Vein and Posterior Wall Isolation: A Charge Density Mapping Study

Background: Non-contact charge density (CD) mapping allows a global visualization of left atrium (LA) activation and of activation patterns during atrial fibrillation (AF). The aim of this study was to analyze, with CD mapping, the changes in persistent AF induced by pulmonary vein isolation (PVI) and LA posterior wall isolation (LAPWI). Methods: Patients undergoing PVI + LAPWI using the Arctic Front Advance PRO^TM cryoballoon system were included in the study. CD maps were created during AF at baseline, after PVI and after LAPWI. Three distinct activation patterns were identified in the CD maps: localized irregular activation (LIA), localized rotational activation (LRA) and focal centrifugal activation (FCA). LA maps were divided into the following regions: anterior, septal, lateral, roof, posterior, inferior. Results: Eleven patients were included, with a total of 33 maps and 198 AF regions analyzed. Global and regional AF cycle lengths significantly increased after PVI and LAPWI. Baseline analysis demonstrated higher LIA, LRA and FCA numbers in the posterior and anterior regions. After PVI, there was no change in LIA, LRA and FCA occurrence. After PVI + LAPWI, a significant decrease in LRA was observed with no difference in LIA and FCA occurrence. In the regional analysis, there was a significant reduction in the LIA number in the inferior region, in the LRA number in the roof and posterior regions and in the FCA number in the lateral region. Conclusions: A global reduction in the LRA number was observed only after PVI + LAPWI; it was driven by a reduction in rotational activity in the roof and posterior regions.

Feasibility and safety of left atrial posterior wall isolation with a new Cryoballoon technology in patients with persistent atrial fibrillation

BACKGROUND

Left atrial posterior wall isolation (LAPWI) is often performed in addition to pulmonary vein isolation (PVI) in the setting of persistent atrial fibrillation (AF) ablation. The aim of this study was to evaluate the feasibility and safety of a new cryoballoon ablation system in achieving PVI + LAPWI isolation.

METHODS

The study was a prospective, non-randomized, single center study. Forty consecutive patients, undergoing PVI + LAPWI with the novel POLARx™, were compared to 40 consecutive patients who underwent the same procedure with the established Arctic Front Advance PRO™.

RESULTS

Acute isolation was achieved in all PVs in both groups and left posterior wall isolation (LAPWI) was achieved in 38 patients (95%) in the POLARx group and in 36 patients (90%) in Arctic Front group. Procedural outcomes were similar between both groups, except for lower temperatures during cryoenergy in the POLARx group, for both pulmonary vein isolation (PVI) and LAPWI.

CONCLUSION

LAPWI + PVI with the novel POLARx™ Cryoballoon is feasible and safe; the results are comparable with the Arctic Front Advance PRO™ system.