Impact of Left Common Pulmonary Veins in the Contact-Force vs. Cryoballoon Atrial Fibrillation Ablation (CIRCA-DOSE) Study

Impact of pulmonary vein anatomy and ostial dimensions on long-term outcome after single-shot device-guided cryoablation for paroxysmal atrial fibrillation

BACKGROUND

Cryoballoon (CB)-guided pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). This observational study aimed to assess the role of individual anatomical characteristics to predict long-term freedom from arrhythmia recurrence after CB-guided PVI for paroxysmal AF (PAF).

METHODS

Three hundred fifty three consecutive patients (58 ± 11 years, 56% males), undergoing PVI between 2012 and 2018 were analysed. Individual pulmonary vein (PV) anatomy was assessed using preprocedural cardiac magnetic resonance imaging (MRI). For each PV, the cross-sectional area (CSA) was calculated. The impact of PV characteristics and CSA on long-term AF-free survival was evaluated.

RESULTS

Acute PVI was achieved in all patients. Two hundred twenty-three patients (63%) had a normal PV anatomy (2 left- and 2 right-sided PV). Variant PV anatomy was present in 130 patients (37%). During the observation period of 48 months, AF-recurrence was documented in 167 patients (47 %). Patients with AF-recurrence presented with significantly enlarged right-sided PVs and left superior PVs (LSPVs) (p < 0.001). The presence of left common PVs (LCPVs) (n = 75, Log-rank p < 0.001) as well as right variant PVs (n = 35, Log rank p < 0.001) was associated with a significantly impaired long-term AF-free survival rate as compared to patients with normal PV characteristics.

CONCLUSION

Variant PV anatomy is a good predictor for AF-recurrence. A correlation between an enlarged CSA of right-sided PVs as well as LSPVs and AF-recurrence was documented.

Ablation therapies for paroxysmal atrial fibrillation: A systematic review and patient-level network meta-analysis

Introduction: Despite promising trials, catheter ablation is still regarded as an adjunct to antiarrhythmic drugs (AADs) in the treatment of paroxysmal atrial fibrillation (PAF). This study aimed to compare the effectiveness of various ablation therapies and AAD. Method: Randomised controlled trials or propensity score-matched studies comparing atrial tachyarrhythmia recurrence among any combination of ablation modalities or AAD were retrieved. Kaplan-Meier curves and risk tables for this outcome were graphically reconstructed to extract patient-level data. Frequentist network meta-analysis (NMA) using derived hazard ratios (HRs), as well as 2 restricted mean survival time (RMST) NMAs, were conducted. Treatment strategies were ranked using P-scores. Results: Across 24 studies comparing 6 ablation therapies (5,132 patients), Frequentist NMA-derived HRs of atrial fibrillation recurrence compared to AAD were 0.35 (95% confidence interval [CI]=0.25–0.48) for cryoballoon ablation (CBA), 0.34 (95% CI=0.25–0.47) for radiofrequency ablation (RFA), 0.14 (95% CI=0.07–0.30) for combined CBA and RFA, 0.20 (95% CI=0.10–0.41) for hot-balloon ablation, 0.43 (95% CI=0.15–1.26) for laser-balloon ablation (LBA), and 0.33 (95% CI=0.18–0.62) for pulmonary vein ablation catheter. RMST-based NMAs similarly showed significant benefit of all ablation therapies over AAD. The combination of CBA + RFA showed promising long-term superiority over CBA and RFA, while LBA showed favourable short-term efficacy. Conclusion: The advantage of ablation therapies over AAD in preventing atrial tachyarrhythmia recurrence suggests that ablation should be considered as the first-line treatment for PAF in patients fit for the procedure. The promising nature of several specific therapies warrants further trials to elicit their long-term efficacy and perform a cost-benefit analysis. Keywords: Atrial fibrillation, catheter ablation, network meta-analysis

Impact of the left common ostium following pulmonary vein isolation in AF : Systematic review and meta‐analysis

Purpose

Pulmonary vein isolation (PVI) through catheter ablation is the basis for the treatment of atrial fibrillation (AF). The left common ostium (LCO) is a high prevalence anatomical variation and has conflicting results in the effects on the prognosis following ablation. We undertook a systematic review and meta‐analysis of studies that compared the arrhythmia recurrence rate after radiofrequency ablation or cryoablation balloon between patients with normal pattern pulmonary vein and patients with LCO.

Methods and Results

Results were pooled using a fixed or random effect, at the discretion of heterogeneity (>25%), in addition, we associated subgroup analysis in these cases and when clinically indicated. Fourteen non‐randomized studies totaling 3278 patients were included. In analyses using the two energies all patients: OR 1.01 (95% CI 0.84–1.23; P = .90, I² = 67%) and excluding patients with any type of persistent AF (PeAF) and those submitted to linear atrial lesion (LAL) OR 0.80 (95% CI 0.52–1.22; P = .30, I² = 71%). Using CRYO: all patients OR 1.34 (95% CI 1.03–1.74; P = .03, I² = 0%). Using RF: all patients—OR 0.55 (95% CI 0.32–0.95; P = .03, I² = 49%); excluding studies with long duration PeAF and the performance of LAL concomitant—OR 0.45 (95% CI 0.23–0.91; P = .03, I² = 44%).

Conclusion

The results suggest a better prognosis in patients with LCO, submitted to PVI without additional LAL under RF energy in paroxysmal AF and short‐duration PeAF. In patients undergoing CRYO, the presence of LCO suggests a worse prognosis.

Unique Left Pulmonary Vein Isolation in Straight Common Trunk Based on Longitudinal Conduction of Left Lateral Ridge

BACKGROUND

A left common pulmonary vein (LCPV) is the most common anatomical variation in the pulmonary vein (PV) and often influences strategies of PV isolation for atrial fibrillation (AF). Our objective was to elucidate the electrical properties of the specific shape of LCPV and to apply it to an ablation procedure.

METHODS AND RESULTS

We investigated consecutive 12 out of 204 paroxysmal AF patients who had the shape of a straight common trunk in LCPV defined by the formation of a single conduit with parallel cranial and caudal walls after the coalescence of superior and inferior pulmonary veins on the distal side. The distance between the top of the bifurcation of LPVs and the level coinciding with the middle of the anterior wall of LCPV (left lateral ridge: LLR) was more than 10 mm in all the patients. The activation pattern of the LLR showed longitudinal conduction without outside connections. All the LCPV except one were successfully isolated without ablating the LLR (C-shape ablation). Only one patient had AF recurrence during the follow-up period.

CONCLUSION

The LLR in LCPV with a straight common trunk has longitudinal conduction without outside connections, which permits the isolation of LCPV without ablating LLR. This article is protected by copyright. All rights reserved.