Does isolation of the left atrial posterior wall using cryoballoon ablation improve clinical outcomes in patients with persistent atrial fibrillation? A prospective randomized controlled trial

Evaluating the Effectiveness of Combined Left Atrial Posterior Wall Linear Ablation and Pulmonary Vein Isolation in Reducing Long-Term Recurrence Rates After Surgery in Patients with Persistent Atrial Fibrillation: A Randomized Controlled Trial

PURPOSE

This study aimed to evaluate whether combining left atrial posterior wall linear ablation with PVI (LAPVI) improves long-term outcomes in patients with persistent AF.

METHODS

In a randomized controlled trial, 228 patients with persistent AF underwent PVI and were randomly assigned to either receive additional LAPVI or not. Procedures used a standardized protocol under general anesthesia. Outcomes, including sinus rhythm maintenance and recurrence rates of AF, were assessed at 6 months, 1 year, and 2 years post-procedure. Statistical analysis was performed using the chi-square test for categorical variables and t-tests for continuous variables.

RESULTS

At 2 years, 74.77% of the LAPVI group maintained sinus rhythm compared to 54.7% in the PVI group (P = 0.002). Recurrence rates of paroxysmal and persistent AF were significantly lower in the LAPVI group at 11.71% and 9.01%, respectively, versus 24.79% and 20.51% in the PVI group (P < 0.05). Antiarrhythmic drug use was significantly reduced in the LAPVI group at each follow-up interval (P < 0.05).

CONCLUSION

LAPVI significantly enhances long-term rhythm control and reduces dependence on antiarrhythmic drugs compared to PVI alone in patients with persistent AF.

The role of left atrium posterior wall isolation in patients undergoing catheter ablation for atrial fibrillation

The posterior left atrium (LAPW) is an important substrate for initiation and maintenance of atrial fibrillation (AF). While it has been proposed as a potential target for preventing recurrence of atrial tachyarrhythmias, it remains unclear whether electrical silence of LAPW offers additional benefits over pulmonary vein isolation (PVI) alone. We conducted a systematic review of PubMed, Medline, Embase, and Cochrane databases and identified 21 eligible studies, encompassing 1514 patients assigned to PVI + posterior wall isolation (PWI) group and 1629 patients assigned to PVI group. Over a median follow-up of 12 months, adjunctive PWI significantly improved the atrial tachyarrhythmia-free survival by 14 % in comparison to PVI alone [relative risk (RR): 1.14, 95 % confidence interval (CI): 1.04 to 1.25, p = 0.004]. This improvement was mainly attributed to a pronounced benefit for patients with persistent AF. In addition, patients undergoing PVI + PWI had a longer procedure time [weighted mean difference (WMD): 23.85, 95 % CI: 12.68 to 35.01, p < 0.001], ablation time (WMD: 9.27, 95 % CI: 5.19 to 13.54, p < 0.001), and a nearly negligible increase in fluoroscopic exposure (WMD: 2.69, 95 % CI: -0.23 to 5.62, p = 0.071). There was no increased risk of procedure-related complications between these approaches (RR: 1.06, 95 % CI: 0.71 to 1.57, p = 0.787). Compared with PVI alone, PWI adjunctive to PVI exhibited a higher procedure success of sinus rhythm maintenance in persistent AF during an index catheter ablation. Meanwhile, elongated procedure time and ablation time did not compromise the safety of extensive ablation strategy with additional PWI.

Posterior left atrial wall isolation for treatment of persistent atrial fibrillation during first-time catheter ablation: An updated systematic review and meta-analysis

BACKGROUND

Although catheter ablation (CA) by mean of pulmonary vein isolation (PVI) is nowadays the mainstay treatment for atrial fibrillation (AF), its success-rate in persistent AF remains suboptimal. Results from studies evaluating whether adding posterior wall isolation (PWI) to PVI can increase the success-rate of CA in persistent AF have yielded conflicting data. The aim of this meta-analysis was to assess whether PWI plus PVI might be beneficial in patients with persistent AF.

METHODS

Electronic databases were searched for randomized control trials (RCTs) and observational studies that compared clinical outcomes between patients with persistent AF who underwent PVI with or without PWI.

RESULTS

Fifteen studies, including a total of 3072 patients, were considered (1533 treated with PVI and 1539 with PWI + PVI). Comparing patients treated with or without PWI, no statistically significant difference was found in the risk of any atrial tachyarrhythmias recurrence after CA (RR 0.83; 95 % CI 0.66-1.03). The analyses detected a statistically significant reduction in the risk of AF in patients treated with PWI (RR 0.63; 95 % CI 0.48-0.84) balanced by a trend towards an increased risk of atrial flutter/atrial tachycardia (RR 1.51; 95 % CI 0.92-2.49). No statistically significant differences were identified in the risk of major procedural complications (RR 0.94; 95 % CI 0.50-1.78).

CONCLUSIONS

According to our updated meta-analysis, the addition of PWI to PVI was not associated with a reduction of atrial arrhythmia recurrences. A reduction of the risk of AF recurrence and a trend towards an increased risk of atrial flutter/atrial tachycardia were identified.

Adjunctive posterior wall isolation for patients with persistent atrial fibrillation: A systematic review and meta-analysis

Background

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Its effectiveness for persistent atrial fibrillation (PeAF) is limited, and the benefits of adjunctive posterior wall ablation are uncertain.

Objective

The purpose of this study was to perform a systematic review and meta-analysis of PVI with/without adjunctive PWI in patients with PeAF.

Methods

We systematically searched PubMed, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing PVI with/without PWI in patients with PeAF. Random-effects model was used for the meta-analysis. Atrial tachyarrhythmia (ATA) was a composite of AF, atrial flutter, or atrial tachycardia.

Results

Our meta-analysis included eight RCTs with 1104 patients (546 PVI, 558 PVI plus PWI). Compared with PVI alone, adjunctive PWI significantly increased freedom from ATA recurrence (relative risk [RR] 1.13, 95% confidence interval [CI] 1.01-1.27, P = .036). A subanalysis of patients with long-standing PeAF showed a greater effect of PWI (RR 1.76, 95% CI 1.02-3.04, P = .04). A subgroup analysis of PWI techniques indicated no significant difference for ATA recurrence with box isolation alone (RR 1.13, 95% CI 0.97-1.33, P = .12), whereas a pooled analysis using only studies with direct posterior wall ablation favored the adjunctive PWI group (RR 1.39, 95% CI 1.11-1.74, P <.01). Adverse events did not significantly differ between groups.

Conclusion

Our findings support that adjunctive PWI to PVI is an effective strategy compared with PVI alone for reducing ATA recurrence in patients with PeAF without compromising safety. Notably, patients with long-standing PeAF may benefit more from PWI.

Which ablation strategy is the most effective for treating persistent atrial fibrillation? A systematic review and bayesian network meta-analysis of randomized controlled trials

There is no consensus on the most efficient ablation strategy for patients with persistent atrial fibrillation (PerAF). This study aimed to conduct a systematic review and network meta-analysis (NMA) to evaluate the effectiveness of different ablation strategies for PerAF. The primary efficacy outcome was the recurrence of any atrial arrhythmia after a single ablation procedure during the follow-up period. The primary safety outcome of interest was any reported complication related to the procedure. The secondary outcome was the procedure time. Fifty-two studies with 9048 patients were included in this NMA. The studies were conducted between 2004 and 2024, and 22 different ablation strategies were identified. Pulmonary vein isolation + posterior wall box isolation + extra-pulmonary vein isolation was the most effective ablation therapy for PerAF. Most additional substrate modification ablation strategies do not show significant additional benefits. There were no significant differences in the incidence of procedure-related complications between the different ablation strategies. Pulmonary vein isolation combined with additional ablation sites increases the duration of the procedure.

Efficacy and Safety of Adjunctive Posterior Wall Isolation in Patients with Persistent Atrial Fibrillation: A Systematic Review and Meta-Analysis

BACKGROUND

In patients with persistent atrial fibrillation (AF), addition of posterior wall isolation (PWI) to pulmonary vein isolation (PVI) is controversial.

OBJECTIVE

Compare PVI plus PWI versus PVI alone in patients with persistent AF.

METHODS

We searched PubMed (by MEDLINE), Embase, LILACS, CENTRAL (by Cochrane Library), and Clinicaltrials.gov databases for randomized trials comparing PVI + PWI and PVI alone in persistent AF. The outcomes were: (i) AF recurrence; (ii) composite of recurrent atrial arrhythmias (i.e., AF, atrial tachycardia, or atrial flutter); (iii) major clinical complications (i.e., pericardial effusion or tamponade, sinus node dysfunction, or atrioesophageal fistula); (iv) mean ablation time. Risk of bias and quality of evidence were evaluated using the Cochrane Risk of Bias 2.0 tool and GRADE, respectively. Statistical significance was set at 5%, and subgroup and sensitivity analyses were performed.

RESULTS

We included eight studies and 1119 patients, of which 561 underwent PVI + PWI. During follow-up (12 - 24 months), recurrence of AF was significantly reduced with adjunctive PWI (RR 0.66, 95% CI 0.44-0.98). Composite of recurrent atrial arrhythmias did not differ significantly (RR 0.83, 95% CI 0.65-1.06). Major clinical complications (RR 0.81, 95% CI 0.42-1.58) were similar, with PVI alone having a shorter mean procedure time (mean difference -23.37 minutes, 95% CI -30.23, -16.50).

CONCLUSION

Adjunctive PWI appears to be effective in improving recurrent AF, but not recurrence of all atrial arrhythmias. Procedure time was longer with PVI + PWI without significant change in overall safety. Further studies should focus on long-term benefit.

Comparative Study of Arctic Front Advance Pro and POLARx Cryoballoons for Linear Ablation of the Left Atrial Roof

BACKGROUND

The effectiveness of cryoballoon ablation (CBA) of the left atrial (LA) roof in addition to pulmonary vein isolation (PVI) using a novel cryoballoon catheter, POLARx, remains unclear.

METHODS

This study compared the efficacy of LA roof line ablation and PVI using POLARx (Boston Scientific) or AFA-Pro (Medtronic) in 100 patients with persistent atrial fibrillation. The right superior pulmonary vein (PV) anchoring and raise-up techniques were consistently used for LA roof line ablation, and rapid right ventricular pacing was applied if the cryoballoon temperature did not reach -40°C.

RESULTS

Complete conduction block at the LA roof could be obtained in all patients with POLARx and in 98.0% of patients with AFA-Pro. Rapid right ventricular pacing was needed in 64.0% of patients with AFA-Pro and in no patients with POLARx. During LA roof line ablation, the nadir cryoballoon temperature was significantly lower with POLARx than with AFA-Pro (right: -54.2°C ± 4.4°C vs. -46.0°C ± 5.4°C; central: -56.8°C ± 4.4°C vs. -45.7°C ± 4.8°C; left: -56.1°C ± 4.3°C vs. -46.1°C ± 5.7°C), and the cryoballoon temperature reached -40°C earlier with POLARx than with AFA-Pro (right: 30.8 ± 7.4 s vs. 74.1 ± 37.7 s; central: 28.2 ± 5.2 s vs. 62.9 ± 30.9 s; left: 29.8 ± 5.8 s vs. 69.6 ± 40.7 s).

CONCLUSION

The nadir cryoballoon temperature with POLARx was approximately 10°C lower than with AFA-Pro, consistently dropping below -40°C during LA roof line CBA. Thus, a complete conduction block of the LA roof line can be easily accomplished using right superior PV anchoring and the raise-up techniques without the need for rapid right ventricular pacing with POLARx.

Adjunctive Left Atrial Posterior Wall Isolation in Treating Non-Paroxysmal Atrial Fibrillation: An Updated Meta-Analysis of Randomized Clinical Trials

BACKGROUND

The clinical outcomes of adjunctive posterior wall isolation (PWI) beyond pulmonary vein isolation (PVI) for non-paroxysmal atrial fibrillation (AF) remain unclear. This meta-analysis was conducted to evaluate the role of PWI in non-paroxysmal AF by pooled analysis of most updated randomized controlled trials (RCTs).

METHODS

A literature search in PubMed, Embase, and the Cochrane Library was performed to identify RCTs comparing the outcomes of PVI with and without PWI in non-paroxysmal AF patients. The primary outcomes were recurrence rates of all atrial arrhythmias, AF, and atrial tachycardia/flutter (AT/AFL). The secondary outcomes included total procedure time, ablation time, fluoroscopy time and procedure-related complications. Estimated risk ratios (RRs) and 95% confidence intervals (CIs) were evaluated.

RESULTS

Nine RCTs with a total of 1,243 non-paroxysmal AF patients were included in our analysis. There were no significant differences in all atrial arrhythmias recurrence (RR: 0.86, 95% CI: 0.66-1.11, p = 0.24, I2 = 49%) and AF recurrence (RR: 0.74, 95% CI: 0.51-1.08, p = 0.12, I2 = 62%) between stand-alone PVI group and PVI plus PWI group. Adjunctive PWI increased the AT/AFL recurrence rate (RR: 1.62 95% CI: 1.08-2.42, p = 0.02, I2 = 0%). In the subgroup analysis, PWI using cryoballoon ablation was associated with a significantly lower recurrence rate of all atrial arrhythmias (p = 0.01) and AF (p = 0.02) recurrence and similar recurrence rate of AT/AFL (p = 0.15). Additional PWI was associated with an increased AT/AFL recurrence (p = 0.03) in patients with left atrial diameter (LAD) <44 mm. Adjunctive PWI needed longer ablation time, fluoroscopy time, and total procedure time. The incidence of procedural adverse events was low and similar between both groups.

CONCLUSION

Adjunctive PWI beyond PVI did not improve the freedom from all atrial arrhythmias and AF with an increased recurrence rate of AT/AFL in non-paroxysmal AF patients. The ablation energy and LAD might affect the clinical outcome of PWI. However, larger more RCTs were needed to verify our findings.

Pulsed Field Ablation in Atrial Fibrillation: Initial Experience of the Efficacy and Safety in Pulmonary Vein Isolation and Beyond

Regional differences in pulsed field ablation (PFA) adoption for pulmonary vein isolation (PVI) with additional posterior wall ablation (PWA) in Asia remains unknown. We hereby report our experience on the safety and efficacy of PFA in AF ablation. Consecutive AF patients who underwent PFA from September 2022 to January 2024 were included. The primary efficacy endpoint was freedom from atrial arrhythmia recurrence after a 90-day blanking period at 12 months. Safety endpoints included 30 days of all-cause death, cardiac tamponade, stroke, myocardial infarction, and heart failure hospitalization. One hundred and one (72.3% males, 79.2% pAF) patients underwent PFA for AF. Thirty-one (30.7%) had structural heart disease with mean LVEF of 57.4 ± 8.1% and CHA2DS2-VASc score of 1.4 ± 1.3. Twenty-nine (28.7%) underwent additional PWA (PVI + PWA) using PFA. PWA was acutely successful in all patients. Patients who underwent PWA were more likely to have persistent AF and require general anesthesia and electroanatomic mapping (all p < 0.05). Total PFA applications for PVI, LA dwell time, procedural time, and fluoroscopy time were similar between the PVI-only and PVI + PWA groups (all p > 0.05). The 1-year atrial arrhythmia recurrence rates were 10% for pAF and 21% for the persistent AF group. The primary efficacy endpoint was not significantly different between the PVI-only and PVI+PWA groups (12-month KM estimates 90.3% [95% CI, 83.3-97.3] and 82.8% [95% CI, 68.1-97.4], respectively). There were no complications related to PFA use. PFA can be safely, effectively, and efficiently adopted for AF ablation. Additional PWA, if pursued, had similar procedural metrics to the PVI-only strategy without increased complications.

Clinical impact of cryoballoon posterior wall isolation using the cross-over technique in persistent atrial fibrillation

BACKGROUND AND AIMS

Successful left atrial posterior wall isolation (LAPWI) using only the cryoballoon (CB) is technically challenging for the treatment of atrial fibrillation (AF). This study aimed to evaluate the efficacy of the cross-over technique, wherein an overlapped ablation is performed by placing the CB from both directions in contact with the LAPW.

METHODS

This was a single-center, retrospective, observational study of 194 consecutive patients with persistent atrial fibrillation (PerAF) who underwent a first-time procedure of pulmonary vein isolation (PVI) + PWI (108 patients) or PVI-only (86 patients) using the CB. The cross-over technique was applied in all LAPWI.

RESULTS

For ablation of the LA roof and bottom, respectively, a mean of 8.6 ± 1.0 (right to left [R→L] 4.3 ± 1.1 and left to right [L→R] 4.3 ± 1.1) and 9.1 ± 1.2 (R→L 4.6 ± 1.6 and L→R 4.5 ± 1.2) CB applications were delivered. LAPW was successfully isolated solely using the CB in 99.1% of patients. Although the PVI + PWI group had significantly longer procedure time, no severe adverse events were observed in either group. During a median follow-up of 19 months, freedom from recurrence of all atrial tachyarrhythmias was achieved in 93.5% of the PVI + PWI group and 72.9% of the PVI-only group (p = .011).

CONCLUSIONS

LAPWI performed solely with the CB using the cross-over technique is feasibly, safe, and was independently associated with a significantly higher freedom from recurrence of atrial tachyarrhythmias compared with PVI alone in patients with PerAF.

Catheter ablation using pulmonary vein isolation with versus without left atrial posterior wall isolation for persistent atrial fibrillation: an updated systematic review and meta-analysis

BACKGROUND

Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation of atrial fibrillation (AF); however, the results are suboptimal for persistent AF. The left atrial posterior wall (LAPW) is thought to be a major additional area in initiation and perpetuation of persistent AF. Therefore, adjunctive ablation of the posterior wall may reduce AF recurrence in patients with persistent AF.

OBJECTIVE

The objective of this study was to compare outcomes of catheter ablation in patients with persistent AF using PVI alone versus a combination of PVI and LAPW isolation.

METHODS

Literature search was conducted in PubMed, PubMed Central, Scopus, and Embase since inception to February 2023. Screening of studies was done via Covidence software. Risk of bias assessment was done using appropriate tools. Data extraction and a narrative synthesis were carried out accordingly.

RESULTS

Ten studies were included, of which five were randomized controlled trials. PVI with LAPW ablation group had significantly lower recurrence of overall atrial tachyarrhythmia (OR 0.47, CI 0.32-0.70) and AF (OR 0.39, CI 0.23-0.69). In sensitivity analysis, freedom from atrial arrhythmias was noted to be significantly higher in the PVI with LAPW ablation group (OR 2.22, CI 1.36-3.64). However, there was no significant difference in occurrence of atrial flutter (OR 1.36, CI 0.86-2.14) or with periprocedural adverse events (OR 1.10, CI 0.60-1.99).

CONCLUSION

LAPW ablation, in addition to PVI, significantly improves the rates of arrhythmia freedom and reduces the recurrence of overall atrial tachyarrhythmia. There was no significant difference in atrial flutter or periprocedural adverse events.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

Adjunctive left atrial posterior wall isolation for atrial fibrillation: An updated systematic review and meta-analysis

OBJECTIVE

Posterior left atrial wall isolation (PWI) plus traditional pulmonary vein isolation (PVI) has been proposed as a promising intervention to decrease atrial fibrillation (AF) recurrence. We aim to investigate the efficacy and safety of adding PWI to the traditional PVI in patients with AF.

METHODS

A systematic review and meta-analysis was conducted using synthesizing randomized controlled trials (RCTs) retrieved by systematically searching PubMed, Web of Science, SCOPUS, EMBASE, and Cochrane through June 14, 2023. We used Stata version 17 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), with a 95% confidence interval (CI) (PROSPERO ID: CRD42023446227).

RESULTS

We included 11 RCTs with a total number of 1534 patients. Combined ablation with PWI + PVI was not associated with any significant difference over PVI only regarding the recurrence of clinical AF (RR: 0.86 with 95% CI [0.70-1.06]), all atrial arrhythmia (RR: 0.93 with 95% CI [0.82-1.07]), nonatrial fibrillation arrhythmia (RR: 1.22 with 95% CI [0.97-1.53]), early AF (RR: 0.89 with 95% CI [0.62-1.27]), and antiarrhythmic drugs at discharge (RR: 0.83 with 95% CI [0.67-1.04]). However, it was associated with increased total ablation duration (minutes) (MD: 12.58 with 95% CI [6.80-18.37]) and total procedure duration (minutes) (MD: 16.77 with 95% CI [9.63-23.91]), without any significant difference regarding adverse events (RR: 1.05 with 95% CI [0.63-1.74]).

CONCLUSION

While the pooled data from PWI + PVI using point-by-point radiofrequency did not suggest a benefit in the recurrence of various atrial arrhythmias compared to PVI alone, PWI+PVI using direct posterior wall ablation, especially with cryoballoon, demonstrated a significant reduction in recurrence of AF/atrial arrhythmias. Also, PWI + PVI significantly increased the ablation and total procedure durations.

In Silico TRials guide optimal stratification of ATrIal FIbrillation patients to Catheter Ablation and pharmacological medicaTION: the i-STRATIFICATION study

AIMS

Patients with persistent atrial fibrillation (AF) experience 50% recurrence despite pulmonary vein isolation (PVI), and no consensus is established for secondary treatments. The aim of our i-STRATIFICATION study is to provide evidence for stratifying patients with AF recurrence after PVI to optimal pharmacological and ablation therapies, through in silico trials.

METHODS AND RESULTS

A cohort of 800 virtual patients, with variability in atrial anatomy, electrophysiology, and tissue structure (low-voltage areas, LVAs), was developed and validated against clinical data from ionic currents to electrocardiogram. Virtual patients presenting AF post-PVI underwent 12 secondary treatments. Sustained AF developed in 522 virtual patients after PVI. Second ablation procedures involving left atrial ablation alone showed 55% efficacy, only succeeding in the small right atria (<60 mL). When additional cavo-tricuspid isthmus ablation was considered, Marshall-PLAN sufficed (66% efficacy) for the small left atria (<90 mL). For the bigger left atria, a more aggressive ablation approach was required, such as anterior mitral line (75% efficacy) or posterior wall isolation plus mitral isthmus ablation (77% efficacy). Virtual patients with LVAs greatly benefited from LVA ablation in the left and right atria (100% efficacy). Conversely, in the absence of LVAs, synergistic ablation and pharmacotherapy could terminate AF. In the absence of ablation, the patient's ionic current substrate modulated the response to antiarrhythmic drugs, being the inward currents critical for optimal stratification to amiodarone or vernakalant.

CONCLUSION

In silico trials identify optimal strategies for AF treatment based on virtual patient characteristics, evidencing the power of human modelling and simulation as a clinical assisting tool.

Impact of Left Atrial Posterior Wall Ablation During Pulsed-Field Ablation for Persistent Atrial Fibrillation

BACKGROUND

Pulmonary vein isolation (PVI) alone is insufficient to treat many patients with persistent atrial fibrillation (PersAF). Adjunctive left atrial posterior wall (LAPW) ablation with thermal technologies has revealed lack of efficacy, perhaps limited by the difficulty in achieving lesion durability amid concerns of esophageal injury.

OBJECTIVES

This study aims to compare the safety and effectiveness of PVI + LAPW ablation vs PVI in patients with PersAF using pulsed-field ablation (PFA).

METHODS

In a retrospective analysis of the MANIFEST-PF (Multi-National Survey on the Methods, Efficacy, and Safety on the Post-approval Clinical Use of Pulsed Field Ablation) registry, we studied consecutive PersAF patients undergoing post-approval treatment with a pentaspline PFA catheter. The primary effectiveness outcome was freedom from any atrial arrhythmia of ≥30 seconds. Safety outcomes included the composite of acute and chronic major adverse events.

RESULTS

Of the 547 patients with PersAF who underwent PFA, 131 (24%) received adjunctive LAPW ablation. Compared to PVI-alone, patients receiving adjunctive LAPW ablation were younger (65 vs 67 years of age, P = 0.08), had a lower CHA2DS2-VASc score (2.3 ± 1.6 vs 2.6 ± 1.6, P = 0.08), and were more likely to receive electroanatomical mapping (48.1% vs 39.0%, P = 0.07) and intracardiac echocardiography imaging (46.1% vs 17.1%, P < 0.001). The 1-year Kaplan-Meier estimate for freedom from atrial arrhythmias was not statistically different between groups in the full (PVI + LAPW: 66.4%; 95% CI: 57.6%-74.4% vs PVI: 73.1%; 95% CI: 68.5%-77.2%; P = 0.68) and propensity-matched cohorts (PVI + LAPW: 71.7% vs PVI: 68.5%; P = 0.34). There was also no significant difference in major adverse events between the groups (2.2% vs 1.4%, respectively, P = 0.51).

CONCLUSIONS

In patients with PersAF undergoing PFA, as compared to PVI-alone, adjunctive LAPW ablation did not improve freedom from atrial arrhythmia at 12 months.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

Clinical Outcomes of Intracardiac Echocardiography-Guided Contrast Agent-Free Cryoballoon Ablation in Atrial Fibrillation Patients With Renal Insufficiency

BACKGROUND AND OBJECTIVES

Previous studies have reported an association between impaired renal function and poor outcomes after radiofrequency catheter ablation in patients with atrial fibrillation (AF). However, outcomes of cryoballoon ablation (CBA) in patients with renal insufficiency are not fully elucidated. This study aimed to compare outcomes of CBA in AF patients with chronic kidney disease (CKD) versus those without CKD and to assess changes in renal function over 12 months following CBA.

METHODS

A total of 839 patients (65.1% with non-paroxysmal AF [PAF]) who underwent de novo CBA were prospectively enrolled. We divided patients into two groups based on creatinine clearance rate (CCr) and performed intracardiac echocardiography (ICE)-guided contrast agent-free CBA.

RESULTS

In comparison with patients without CKD (CCr >50, n=722), those with CKD (CCr ≤50, n=117) were older and predominantly female, had a lower body mass index, and showed a higher prevalence of heart failure and hypertension. Mean CHA2DS2-VAS score was significantly higher in CKD group than in non-CKD group. Procedure-related complications were not significantly different between two groups. During a mean follow-up period of 25.4±11.9 months, clinical recurrence occurred in 182 patients (21.7%) and not significantly different between two groups. In multivariate analysis, non-PAF and left atrial size were independent predictors of AF recurrence. CCr levels significantly improved over 12 months after CBA in CKD group.

CONCLUSIONS

ICE-guided contrast-agent-free CBA showed comparable long-term clinical outcomes without increasing procedure-related complications and improvement of renal function over 12 months following CBA in AF patients with CKD.

Left atrial roof region ablation using a visually guided laser balloon

Balloon-based catheter ablation including visually guided laser balloon (VGLB) has been adopted a first line therapeutic strategy for the patients with atrial fibrillation (AF). Recently, the roof area ablation beyond pulmonary vein (PV) isolation (PVI) using cryoballoon has been described as an effective therapy for the patients with persistent AF. However, the roof area ablation performed with a VGLB remains unknown. In this case, we report the case of roof area ablation for the patient with persistent AF using a VGLB.

Variation in the frozen lesion size according to the non-occluded application duration and technique for cryoballoon ablation

OBJECTIVE

The frozen lesion formation created by cryoballoon ablation, especially with non-occluded applications, has not been fully evaluated. This study aimed to validate the lesion size under different cryoballoon ablation settings: application duration, push-up technique, and laminar flow.

METHODS

The frozen lesion size was evaluated immediately after ending the freezing with three different application durations (120, 150, and 180 seconds) in porcine hearts (N = 24). During the application, the push-up technique was applied at 10, 20, and 30 seconds after starting the freezing with or without laminar flow.

RESULTS

The lesion size was significantly correlated with the nadir balloon temperature (P<0.001). The lesion volume became significantly larger after 150 seconds than 120 seconds (1272mm3 versus 1709mm3, P = 0.004), but not after 150 seconds (versus 1876mm3 at 180 seconds, P = 0.29) with a comparable nadir balloon temperature. Furthermore, the lesion volume became significantly larger with the push-up technique with the largest lesion size with a 20-second push-up after the freezing (1193mm3 without the push-up technique versus 1585mm3 with a push-up at 10 seconds versus 1808mm3 with a push-up at 20 seconds versus 1714mm3 with a push-up at 30 seconds, P = 0.04). Further, the absence of laminar flow was not associated with larger lesion size despite a significantly lower nadir balloon temperature.

CONCLUSION

The frozen lesion size created by cryoballoon ablation became larger with longer applications at least 150 seconds and with a push-up technique especially at 20 seconds after the freezing.

Posterior wall ablation by pulsed-field ablation: procedural safety, efficacy, and findings on redo procedures

AIMS

The left atrial posterior wall is a potential ablation target in patients with recurrent atrial fibrillation despite durable pulmonary vein isolation or in patients with roof-dependent atrial tachycardia (AT). Pulsed-field ablation (PFA) offers efficient and safe posterior wall ablation (PWA), but available data are scarce.

METHODS AND RESULTS

Consecutive patients undergoing PWA using PFA were included. Posterior wall ablation was performed using a pentaspline PFA catheter and verified by 3D-electroanatomical mapping. Follow-up was performed using 7-day Holter ECGs 3, 6, and 12 months after ablation. Recurrence of any atrial arrhythmia lasting more than 30 s was defined as failure. Lesion durability was assessed during redo procedures. Posterior wall ablation was performed in 215 patients (70% males, median age 70 [IQR 61-75] years, 67% redo procedures) and was successful in all patients (100%) by applying a median of 36 (IQR 32-44) PFA lesions. Severe adverse events were cardiac tamponade and vascular access complication in one patient each (0.9%). Median follow-up was 7.3 (IQR 5.0-11.8) months. One-year arrhythmia-free outcome in Kaplan-Meier analysis was 53%. A redo procedure was performed in 26 patients (12%) after a median of 6.9 (IQR 2.4-11) months and showed durable PWA in 22 patients (85%) with only minor lesion regression. Among four patients with posterior wall reconnection, three (75%) presented with roof-dependent AT.

CONCLUSION

Posterior wall ablation with this pentaspline PFA catheter can be safely and efficiently performed with a high durability observed during redo procedures. The added value of durable PWA for the treatment of atrial fibrillation remains to be evaluated.

How to perform effective cryoballooon ablation of the left atrial roof: Considerations after experiencing more than 1000 cases

INTRODUCTION

Cryoballoon ablation (CBA) of the left atrial (LA) roof in addition to a pulmonary vein isolation has been expected to improve the clinical outcomes post-atrial fibrillation (AF) ablation. We demonstrated the characteristics and efficacy of CBA of the LA roof through our experience with a large volume of procedures.

METHODS

Among 1036 AF ablation procedures with CBA of the LA roof, 834 patients who underwent a de novo ablation were analyzed.

RESULTS

Complete LA roof line conduction block was obtained in 767 patients (92.0%) solely by CBA (Group A). Compared with the other patients (Group B), the mean nadir balloon temperature during CBA of the LA roof (-44.5 ± 5.6°C for Group A vs. -40.5 ± 7.5°C for Group B, p < .01) and number of cryoballoon applications during the LA roof ablation with a circular mapping catheter located in the left superior pulmonary vein (1.3 ± 0.8 for Group A vs. 1.6 ± 1.0 for Group B, p = .02) were significantly lower in Group A. A multivariate analysis revealed that those were predictors of a complete LA roof conduction block after only CBA. The 1-year Kaplan-Meier atrial arrhythmia free rate estimates were 80.6% for Group A and 59.0% for Group B (p < .01).

CONCLUSION

Complete LA roof line conduction block could be obtained with a cryoballoon without touch-up ablation in most cases. The LA roof CBA with a circular mapping catheter located in the right superior pulmonary vein was preferable to obtaining complete LA roof conduction block, which was important with regard to the clinical outcomes.

Differences in the feasibility, anatomical parameters predicting procedural difficulty, and isolation area of a left atrial posterior wall isolation using radiofrequency versus cryoballoon catheters

BACKGROUNDS

The difficulty and outcome of the adjunctive left atrial posterior wall isolation (LAPWI) in patients with persistent atrial fibrillation (PersAF) may be affected by the ablation energy used. This study aimed to compare the completion rate, anatomical parameters predicting procedural difficulty, and the isolation area of a LAPWI between the use of radiofrequency (RFA) and cryoballoon ablation (CBA).

METHODS

We enrolled 95 and 93 patients with PersAF who underwent pulmonary vein isolation (PVI)+LAPWI using RFA (RF group) and CBA (CB group), respectively. Preoperative computed tomography was used to evaluate the anatomical features associated with an incomplete LAPWI. Post-ablation 3-dimensional maps were analyzed to quantify the isolation area.

RESULTS

The completion rate of the LAPWI was significantly higher in the RF group than the CB group without touch-up RFA (88.4% vs. 72.0%; p = .005). Predictors of incomplete LAPWI were a longer left inferior pulmonary vein (LIPV)-esophageal distance (p < .001) for RFA and a steeper angle of the LAPW (p < .001) and longer transverse LAPW diameter (p = .016) for CBA. The isolated non-PV area with RFA or CBA alone was significantly greater in the CB group than the RF group (27.5 ± 9.5 cm2 vs. 22.9 ± 6.9 cm2 ; p < .001).

CONCLUSION

The position of the esophagus at a distance from the LIPV was associated with an incomplete LAPWI using RFA, while a steeper angle of the LAPW and transverse enlargement of the LAPW were associated with that using CBA. The completion rate of the LAPWI was higher with RFA, but the isolation area outside of the PVs was greater with CBA.

Adjunct posterior wall isolation reduces the recurrence of atrial fibrillation in patients undergoing cryoballoon ablation: A systematic review and meta-analysis

BACKGROUND

Recurrence rates of atrial fibrillation (AF) remain high even after complete wide area circumferential pulmonary vein isolation (PVI). In recent years adjunct posterior wall isolation (PWI) has been performed in patients with more persistent forms of AF but the benefits remain unclear.

AIM

The objective of this meta-analysis was to evaluate the efficacy of adjunct posterior wall isolation in reducing recurrence rates of AF using cryoballoon ablation (CBA).

METHODS

We searched PubMed, Google Scholar, Clinicaltrials.gov and Cochrane CENTRAL. We included studies comparing PVI to PVI + PWI in patients with either persistent or paroxysmal AF (PAF) undergoing CBA. After data extraction and quality assessment of the studies, we assessed recurrence rates of atrial tachy-arrhythmias (AF, atrial flutter, and atrial tachycardia) as well as total ablation time and procedural adverse events. Risk ratio (RR), mean difference (MD), and 95% confidence interval (CI) were calculated using Review Manager.

RESULTS

Concomitant PWI exhibited a substantial reduction in the risk of AF recurrence (RR: 0.51; 95% CI: 0.42-0.63, p < .00001), as well as all atrial arrhythmias (RR: 0.58; 95% CI: 0.49-0.68, p < .00001). On subgroup analysis, in patients with only PAF, adjunct PWI resulted in significant reduction in recurrence risk of AF (RR: 0.56; 95% CI: 0.41-0.76, p = .0002) as well. There was no significant difference in adverse events between both groups (RR: 0.90; 95% CI: 0.44-1.86; p = .78), whereas total ablation time was significantly increased in PVI + PWI group (MD: 21.75; 95% CI: 11.13-32.37, p < .0001).

CONCLUSION

Adjunct PWI when compared to PVI alone decreases recurrence rates of atrial fibrillation after CBA of patients with persistent as well as paroxysmal atrial fibrillation.

Safety and Effectiveness of Adjunctive Posterior Wall Isolation in Atrial Fibrillation Patients: An Updated Meta-Analysis

As the atrial fibrillation (AF) recurrence rate remains high after pulmonary vein isolation (PVI), additional left atrial posterior wall isolation (PWI) has been studied in randomized controlled trials, however, the results are conflicting. We performed an updated meta-analysis by searching online databases for the randomized controlled trials comparing the PWI + PVI group to the PVI alone group in patients with AF. The outcomes of interest were AF recurrence, all atrial arrhythmia recurrence, and atrial flutter/atrial tachycardia (AT) recurrence. Risk ratio (RR) with a 95% confidence interval (CI) was estimated using a random effects model. A total of 1,612 patients, with 807 in the PWI + PVI group and 805 in the PVI alone group were included. The mean age was 60 (9) years, 75% were men and 71% had persistent AF. The PWI + PVI group had lower AF recurrence as compared with the PVI alone group (25% vs 32%, RR 0.73, 95% CI 0.56 to 0.96, p = 0.02). There were no significant differences in all atrial arrhythmia recurrence (RR 0.90, 95% CI 0.78 to 1.04, p = 0.16), atrial flutter/AT recurrence (RR 1.19, 95% CI 0.92 to 1.55, p = 0.19) or adverse event rates in the 2 groups (36 vs 31; RR 1.09, 95% CI 0.67 to 1.77, p = 0.73). In conclusion, adjunctive PWI in addition to PVI can be achieved with lower AF recurrence but with a nonsignificant increase in atrial flutter/AT recurrence, resulting in an overall similar rate of all atrial arrhythmia recurrence without increasing the risk of adverse events, when compared with PVI alone strategy.

Ablative Management of Persistent Atrial Fibrillation (PeAF) with Posterior Wall Isolation (PWI): Where Do We Stand?

Atrial fibrillation is a diverse clinical entity, with persistent atrial fibrillation (PeAF) being particularly challenging to manage. Through this paper, we discuss notable developments in our understanding of ablative strategies for managing PeAF, with a special focus on posterior wall isolation (PWI).

Safety and efficacy of intracardiac echocardiography-guided zero-fluoroscopic cryoballoon ablation for atrial fibrillation: a prospective randomized controlled trial

AIMS

The development of intracardiac echocardiography (ICE) has enabled fluoroless atrial fibrillation (AF) ablation using three-dimensional electroanatomical mapping systems. However, fluoroless cryoballoon ablation (CBA) remains challenging, mainly because of the lack of a visual mapping system. Hence, this study aimed to investigate the safety and efficacy of fluoroless CBA for AF under ICE guidance.

METHODS AND RESULTS

Patients (n = 100) who underwent CBA for paroxysmal AF were randomly assigned to zero-fluoroscopic (Zero-X) and conventional groups. Intracardiac echocardiography was used to guide the transseptal puncture and catheter and balloon manipulation in all enrolled patients. The patients were prospectively followed for 12 months after CBA. The mean age was 60.4 years, and the left atrial (LA) size was 39.4 mm. Pulmonary vein isolation (PVI) was achieved in all patients. In the Zero-X group, fluoroscopy was used in only one patient because of unstable phrenic nerve capture during right-sided PVI. The procedure time and LA indwelling time in the Zero-X group were not statistically different compared with that in the conventional group. Fluoroscopic time (9.0 vs. 0.008 min) and radiation exposure (29.4 vs. 0.02 mGy) were significantly shorter in the Zero-X group than in the conventional group (P < 0.001). The complication rate did not differ between the two groups. During a mean follow-up of 663.3 ± 172.3 days, the recurrence rate was similar (16.0 vs. 18.0%; P = 0.841) between the groups. Multivariate analysis revealed that LA size was the only independent predictor of clinical recurrence.

CONCLUSION

Intracardiac echocardiography-guided fluoroless CBA for AF was a feasible strategy without compromising acute and long-term success or complication rates.

Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA Randomized Clinical Trial

Importance

Pulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison.

Objective

To compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation.

Design, Setting, and Participants

Investigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 1:1 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022.

Interventions

The PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone.

Main Outcomes and Measures

Primary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications.

Results

Among 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, -1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone.

Conclusions and Relevance

In patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF.

Trial Registration

anzctr.org.au Identifier: ACTRN12616001436460.

Risk and benefit of extrapulmonary vein ablation in atrial fibrillation

PURPOSE OF REVIEW

This review aims to summarize the recent development, benefit, and safety of extrapulmonary vein ablation for atrial fibrillation.

RECENT FINDING

Studies have shown that extrapulmonary vein ablation can help maintain normal sinus rhythm for patients with persistent atrial fibrillation. As prior strategies targeting anatomical lines and triggers are well utilized, novel techniques for substrate mapping have been rapidly developing. These strategies are well tolerated and could be chosen based on patients' conditions and physicians' experience.

SUMMARY

Extrapulmonary vein ablation could be safely and effectively performed for patients with atrial fibrillation. It provides further consolidation of normal sinus rhythm.

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.