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Tsiachris D, Doundoulakis I, Antoniou CK, Pagkalidou E, Zafeiropoulos S, Kordalis A, Gatzoulis KA, Chierchia GB, de Asmundis C, Tsioufis K, Stefanadis C. Effectiveness and safety of a time to isolation strategy of cryoballoon ablation of atrial fibrillation: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2022; 33:2640-2648. [PMID: 36177697 DOI: 10.1111/jce.15697] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/10/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022]
Abstract
AIM We conducted a systematic review and meta-analysis of randomized and observational studies with a control group to evaluate the effectiveness and safety of a time to isolation (TTI)-based strategy of cryoballoon ablation (CBA) in the treatment of atrial fibrillation (AF). METHODS Three electronic databases (MEDLINE, Cochrane Central Register of Controlled Trials, and Embase) without language restrictions were searched. The intervention assessed was a TTI-based strategy of CBA in the treatment of AF. TTI was defined as the time from the start of freezing to the last recorded pulmonary veins' potential. The comparison of interest was intended conventional protocol of CBA. The primary endpoint was freedom from atrial arrhythmia. RESULTS Nine studies were deemed eligible (N = 2289 patients). Eight studies reported freedom from atrial arrhythmia and pooled results showed a marginally similar success rate between the two protocols (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 0.98-1.56). A prespecified subgroup analysis verified that a high dose TTI strategy (with >120 s duration of cryotherapy post-TTI) compared to the conventional protocol could significantly increase the patients without atrial arrhythmia during follow-up (OR: 1.39; 95% CI: 1.05-1.83). TTI strategy could also significantly decrease total procedure time (SMD: -26.24 min; 95% CI: -36.90 to -15.57) and phrenic nerve palsy incidence (OR: 0.49; 95% CI: 0.29-0.84). CONCLUSION Moderate confidence evidence suggests that an individualized CBA dosing strategy based on TTI and extended (>2 min post-TTI) duration of CBA is accompanied by fewer recurrences post-AF ablation.
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Affiliation(s)
| | - Ioannis Doundoulakis
- Athens Heart Center, Athens Medical Center, Athens, Greece.,First Department of Cardiology, "Hippokration" Hospital, National and Kapodistrian University, Athens, Greece
| | | | - Eirini Pagkalidou
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, New York, USA.,Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA
| | - Athanasios Kordalis
- Athens Heart Center, Athens Medical Center, Athens, Greece.,First Department of Cardiology, "Hippokration" Hospital, National and Kapodistrian University, Athens, Greece
| | - Konstantinos A Gatzoulis
- First Department of Cardiology, "Hippokration" Hospital, National and Kapodistrian University, Athens, Greece
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Konstantinos Tsioufis
- First Department of Cardiology, "Hippokration" Hospital, National and Kapodistrian University, Athens, Greece
| | - Christodoulos Stefanadis
- Athens Heart Center, Athens Medical Center, Athens, Greece.,Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Liu G, Wang Y, Xu X, Tian J, Lv T. Comparison for the efficacy and safety of time-to-isolation protocol and conventional protocol of cryoballoon in the treatment of atrial fibrillation: a meta-analysis and systematic review. J Interv Card Electrophysiol 2021; 62:259-268. [PMID: 33033904 DOI: 10.1007/s10840-020-00890-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cryoballoon (CB) has been widely utilized in the treatment of drug-refractory atrial fibrillation (AF), but the balance point between efficacy and safety has been unclear. The protocol based on the time-to-isolation (TTI) was expected to provide patients with individualized ablation strategies. METHODS All studies up to June 2020 comparing the CB of TTI-based protocol (TTIP) and conventional protocol (ConP) in PubMed, Embase, and Cochrane Library databases were searched. The pooled OR or SMD with 95% CIs for each outcome were calculated with inverse-variance random effect model. The Egger method was used to evaluate the publication bias and the subgroup analysis was conducted according to the type of atrial fibrillation. RESULTS Six studies enrolling a total of 1770 patients with drug-refractory AF were included. The pool real-time recording of pulmonary veins potential was 71% (95% CI: 61 ~ 81%, I2 = 97.9%) and a similar incidence of freedom from ATs after 1 year (OR: 1.12; 95% CI: 0.86 ~ 1.46, I2 = 0.0%, P = 0.481) was observed between two protocols. No difference was observed in complications (OR: 0.67; 95% CI: 0.43 ~ 1.04, I2 = 0.0%, P = 0.717) and phrenic nerve palsy (OR: 0.70; 95% CI: 0.37 ~ 1.35, I2 = 0.0%, P = 0.807). TTIP could significantly decrease the CB freezes per patient (SMD: - 2.44; 95% CI: - 4.46 to approximately - 0.41; I2 = 99.5%, P = 0.00) and shorten the cryotherapy application time (SMD: - 3.04; 95% CI: - 4.18 to approximately - 1.89; I2 = 97.4%, P = 0.00), procedure time (SMD: - 1.51; 95% CI: - 2.08 to approximately - 0.94; I2 = 95.4%, P = 0.00), and fluorescence time (SMD: - 0.70; 95% CI: - 1.25 to approximately - 0.15; I2 = 95.7%, P = 0.00). CONCLUSION TTIP is safe and effective and it opens a new chapter in the field of individualized protocol of CB for patients with AF.
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Affiliation(s)
- Guolin Liu
- Department of Cardiology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - YuanLi Wang
- Department of Cardiology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Xin Xu
- Department of Cardiology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Jie Tian
- Department of Cardiology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Tiewei Lv
- Department of Cardiology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China.
- Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China.
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Farkowski MM, Karlinski M, Barra S, Providencia R, Golicki D, Pytkowski M, Anic A, Chun JKR, de Asmundis C, Lane DA, Boveda S. Effectiveness and safety of a single freeze strategy of cryoballoon ablation of atrial fibrillation: an EHRA systematic review and meta-analysis. Europace 2021; 24:58-69. [PMID: 34297839 DOI: 10.1093/europace/euab133] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/01/2021] [Indexed: 12/25/2022] Open
Abstract
To conduct a systematic review and meta-analysis to compare the effectiveness and safety of cryoballoon ablation of atrial fibrillation (AF) performed using a single freeze strategy in comparison to an empiric double ('bonus') freeze strategy. We systematically searched MEDLINE, EMBASE, and CENTRAL databases from inception to 12 July 2020, for prospective and retrospective studies of patients undergoing cryoballoon for paroxysmal or persistent AF comparing a single vs. bonus freeze strategy. The main outcome was atrial arrhythmia-free survival and eligible studies required at least 12 months of follow-up; the primary safety outcome was a composite of all complications. Study quality was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa Scale. Thirteen studies (3 randomized controlled trials and 10 observational studies) comprising 3163 patients were eligible for inclusion (64% males, 71.5% paroxysmal AF, mean CHA2DS2-VASc score 1.3 ± 0.9). There was no significant difference in pooled effectiveness between single freeze strategy compared to double freeze strategy [relative risk (RR) 1.03; 95% confidence interval (CI): 0.98-1.07; I2 = 0%]. Single freeze procedures were associated with a significantly lower adverse event rate (RR 0.72; 95% CI: 0.53-0.98; I2 = 0%) and shorter average procedure time (90 ± 27 min vs. 121 ± 36 min, P < 0.001). A trend for lower risk of persistent phrenic nerve palsy was observed (RR 0.61; 95% CI: 0.37-1.01; I2 = 0%). The quality of included studies was moderate/good, with no evidence of significant publication bias. Single freeze strategy for cryoballoon of AF is as effective as an empiric double ('bonus') freeze strategy while appearing safer and probably quicker (PROSPERO registration number CRD42020158696).
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Affiliation(s)
- Michal Miroslaw Farkowski
- 2nd Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Michal Karlinski
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Sergio Barra
- Cardiology Department, Hospital da Luz Arrabida, V. N. Gaia, Portugal
- Cardiology Department, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Rui Providencia
- St Bartholomew's Hospital, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Institute of Health Informatics, University College of London, London, UK
| | - Dominik Golicki
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - Mariusz Pytkowski
- 2nd Department of Heart Arrhythmia, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Ante Anic
- Department for Cardiovascular Diseases, University Hospital Split, Split, Croatia
| | - Julian Kyoung Ryul Chun
- CCB Frankfurt/Med. Klinik III, Markuskrankenhaus, Frankfurt am Main, Germany
- Med. Klinik II, Universtätsklinikum Schleswig Holstein, Campus Lübeck, Germany
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Deirdre Anne Lane
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool, UK
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Serge Boveda
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
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Rzaev FH, Rachkova II, Nikolaeva OA, Gorev MV, Nardaia SG, Makarycheva OV, Vasilieva EY, Shpektor AV. Duration of Applications Affects the Long-Term Efficacy of Cryoballoon Ablation Pulmonary Veins. ACTA ACUST UNITED AC 2021; 61:28-35. [PMID: 33734053 DOI: 10.18087/cardio.2021.1.n1365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022]
Abstract
Aim To evaluate the effect of cryo-exposure duration and the use of the Achieve circular mapping catheter on efficacy of cryoballoon ablation (CBA).Material and methods CBA of pulmonary vein ostia (PVO) is a major method for heart rhythm control in patients with atrial fibrillation (AF). Since the inception, the PVO CBA method has evolved; the recommended application time was changed, and the Achieve circular catheter appeared. We performed a retrospective analysis of PVO CBA administered to patients with AF in the I.V. Davydovsky Municipal Clinical Hospital from 2017 through 2019. The study included 100 patients with available clinical and demographic characteristics and remote results of the intervention. Three patient groups were analyzed based on differences in surgical techniques: group 1, Guidewire / 240 (n=31) with the cryoballoon placing on a guidewire and PVO exposure duration of 240 s; group 2, Guidewire / 180 (n=26) with the cryoballoon placing on a guidewire and PVO exposure duration of 180 s; and group 3, Achieve / 180 (n=43) with the cryoballoon placing on the mapping catheter Achieve and PVO exposure duration of 180 с. The follow-up period was 33.2±4.5, 15.2±6.1, and 12.2±4.1 months in the Guidewire / 240, Guidewire / 180, and Achieve / 180 groups, respectively. The intervention was considered effective when there was no relapse at the time of interview. A relapse of AF was determined as one or more paroxysms recorded on electrocardiogram (ECG) or during 24-h ECG monitoring; the "blind period" (first 3 months after the procedure) was excluded from the follow-up. Safety evaluation included clinically significant complications, such as phrenic nerve damage, hemopericardium, gastroparesis, hemoptysis, acute cerebrovascular disease, and formation of atrio-esophageal fistula. Effects of independent factors were determined with binary logistic regression.Results In the Guidewire / 240 group, efficacy of PVO CBA for the maximum follow-up period was 74.4%, which was significantly different from the value for the Guidewire / 180 group (57.7 %, р=0.015). At the same time, the difference between the Guidewire / 240 and Achieve / 180 groups was statistically non-significant for a comparable follow-up period (р=0.144). Clinically significant complications were absent in all 3 groups. The independent factors that significantly increased the PVO CBA efficacy were the cryo-exposure duration of 240 s compared to 180 s (р= 0.018) and the use of the Achieve catheter (р=0.014).Conclusion Decreasing the cryo-exposure duration to less than 240 s is impractical (in absence of Achieve mapping catheter) since it impairs the long-term efficacy of PVO CBA and does not influence the risk of complications.
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Affiliation(s)
- F H Rzaev
- Clinical City Hospital named after I.V. Davydovsky, Moscow Department of Healthcare, Moscow
| | - Iu I Rachkova
- Clinical City Hospital named after I.V. Davydovsky, Moscow Department of Healthcare, Moscow
| | - O A Nikolaeva
- Clinical City Hospital named after I.V. Davydovsky, Moscow Department of Healthcare, Moscow
| | - M V Gorev
- Clinical City Hospital named after I.V. Davydovsky, Moscow Department of Healthcare, Moscow
| | - Sh G Nardaia
- Clinical City Hospital named after I.V. Davydovsky, Moscow Department of Healthcare, Moscow
| | - O V Makarycheva
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, Moscow
| | - E Yu Vasilieva
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, Moscow
| | - A V Shpektor
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov, Moscow
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Stronati G, Capucci A, Dello Russo A, Adrario E, Carsetti A, Casella M, Donati A, Guerra F. Procedural sedation for direct current cardioversion: a feasibility study between two management strategies in the emergency department. BMC Cardiovasc Disord 2020; 20:388. [PMID: 32842955 PMCID: PMC7449000 DOI: 10.1186/s12872-020-01664-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/10/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND A cardiologist-only approach to procedural sedation with midazolam in the setting of elective cardioversion (DCC) for AF has already been proven as safe as sedation with propofol and anaesthesiologist assistance. No data exist regarding the safety of such a strategy during emergency procedures. The aim of this study is to compare the feasibility of sedation with midazolam, administered by a cardiologist, to an anaesthesiologist-assisted protocol with propofol in emergency DCC. METHODS Single centre, prospective, open blinded, randomized study including all consecutive patients admitted to the Emergency Department requiring urgent or emergency DCC. Patients were randomized in a 1:1 fashion to either propofol or midazolam treatment arm. Patients in the midazolam group were managed by the cardiologist only, while patients treated with propofol group underwent DCC with anaesthesiologist assistance. RESULTS Sixty-nine patients were enrolled and split into two groups. Eighteen patients (26.1%) experienced peri-procedural adverse events (bradycardia, severe hypotension and severe hypoxia), which were similar between the two groups and all successfully managed by the cardiologist. No deaths, stroke or need for invasive ventilation were registered. Patients treated with propofol experienced a greater decrease in systolic and diastolic blood pressure when compared with those treated with midazolam. As the procedure was shorter when midazolam was used, the median cost of urgent/emergency DCC with midazolam was estimated to be 129.0 € (1st-3rd quartiles 114.6-151.6) and 195.6 € (1st-3rd quartiles 147.3-726.7) with propofol (p < .001). CONCLUSIONS Procedural sedation with midazolam given by the cardiologist alone was feasible, well-tolerated and cost-effective in emergency DCC.
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Affiliation(s)
- Giulia Stronati
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Via Conca 71, Ancona, Italy
| | - Alessandro Capucci
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Via Conca 71, Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Via Conca 71, Ancona, Italy
| | - Erica Adrario
- Anaesthesia and Intensive Care Unit, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Ancona, Italy
| | - Andrea Carsetti
- Anaesthesia and Intensive Care Unit, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Via Conca 71, Ancona, Italy
| | - Abele Donati
- Anaesthesia and Intensive Care Unit, Marche Polytechnic University, University Hospital "Ospedali Riuniti", Ancona, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Via Conca 71, Ancona, Italy.
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