Is the time between first diagnosis of paroxysmal atrial fibrillation and cryoballoon ablation a predictor of efficacy?

Effect of early cryoballoon ablation on atrial fibrillation recurrence-A Danish nationwide register study

INTRODUCTION

Cryoballoon ablation is a safe and efficient rhythm control strategy in atrial fibrillation (AF) patients. The impact of time from diagnosis to ablation is unclear. The aim of this study was to examine the impact of timing of first-time cryoballoon ablation on AF recurrence in a nationwide cohort of AF patients.

METHODS AND RESULTS

From nationwide registers, all AF patients ≥18 years of age who underwent first-time AF cryoballoon ablation in Denmark from 2012 to 2018 were included. The AF patients were stratified by ablation timing: Early group (≤1 year after AF diagnosis), intermediate group (1-3 years after AF diagnosis), and late group (≥3 years after AF diagnosis). By adjusted Cox regression models, the effect of timing on AF recurrence was examined. This study included 1064 AF patients with a median age of 63 years. Most patients were male (66%) and had paroxysmal AF (67%). The 1-year risk of AF recurrence increased from 31% in the early group to 41% and 44% in the intermediate and late group. The hazard ratios (95% confidence intervals) were 1.28 (0.95, 1.74) in the intermediate group and 1.42 (1.09, 1.86) in the late group when compared to the early group. Continuous diagnosis-to-ablation time seemed to have the greatest impact on AF recurrence within the first 2 years.

CONCLUSION

In AF patients undergoing cryoballoon ablation, late timing of ablation was associated with a significantly higher AF recurrence rate when compared to early timing of ablation. These findings support early cryoballoon ablation to improve the outcomes after ablation.

Lower Recurrence Rates of Atrial Fibrillation and MACE Events After Early Compared to Late Ablation: A Danish Nationwide Register Study

BACKGROUND

Guidelines recommend prioritizing treatment with antiarrhythmic drugs before referral of patients with atrial fibrillation to ablation, delaying a potential subsequent ablation. However, delaying ablation may affect ablation outcomes. We sought to investigate the impact of duration from diagnosis to ablation on the risk of atrial fibrillation recurrence and adverse events.

METHODS AND RESULTS

Using Danish nationwide registries, all patients with first-time ablation for atrial fibrillation were identified and included from 2010 to 2018. Patients were divided into 4 groups by diagnosis-to-ablation time: <1.0 year (early ablation), 1.0 to 1.9 years, 2.0 to 2.9 years, and >2.9 years (late ablation). The primary end point was atrial fibrillation recurrence after the 90-day blanking period, defined by admission for atrial fibrillation, cardioversions, use of antiarrhythmic drugs, or repeat atrial fibrillation ablations. The secondary end point was a composite end point of heart failure, ischemic stroke, or death, and each event individually. The study cohort consisted of 7705 patients. The 5-year cumulative incidence of atrial fibrillation recurrence in the 4 groups was 42.9%, 54.8%, 55.9%, and 58.4%, respectively. Hazard ratios were 1.20 (95% CI, 1.07-1.35), 1.29 (95% CI, 1.13-1.47), and 1.40 (95% CI, 1.28-1.53), respectively, with the early ablation group as reference. The hazard ratio for the combined secondary end point was 1.22 (95% CI, 1.04-1.44) in the late ablation group compared with the early ablation group.

CONCLUSIONS

In patients undergoing ablation for atrial fibrillation, early ablation was associated with a significantly lower risk of atrial fibrillation recurrence. Furthermore, the associated risk of heart failure, ischemic stroke, or death was significantly lower in early-compared with late-ablation patients.

Timing of cryoballoon pulmonary vein isolation to prevent atrial fibrillation recurrence

BACKGROUND

The aims of this analysis were: to evaluate the impact of timing of ablation on the rate of atrial arrhythmias recurrence, verify if the timing of ablation impact differently in patients with paroxysmal and persistent AF.

METHODS

Three thousand two hundred and five patients (60.5 ± 10 years, female 28.4%%, 78.8%% paroxysmal AF) were included in the analysis. All patients underwent only cryoballoon (CB) pulmonary vein (PV) isolation during the index procedure.

RESULTS

The mean procedure time was 102.8 ± 50 min, with a mean fluoroscopy time of 26.3 ± 49 min. Acute PV isolation was achieved in 11760/11793 (99.7%) PVs. A total of 91 (2.8%) patients experienced a procedure-related complication. During the observation period 913/3205 (28.5%) patients had at least one atrial arrhythmias episode: 28% of patients with paroxysmal AF vs 33% of patients with persistent AF. In multivariate analysis, persistent AF together with time from symptomatic AF diagnosis to ablation, female sex, and ablation time showed to be significant predictors for AF recurrence. In particular, months from first symptomatic AF episode > 18 months was a significant predictor of AF recurrence (HR = 1.23, 95% CI = 1.03-1.46, p = 0.020). In patients with paroxysmal AF, the multivariate analysis confirmed that months from first symptomatic AF episode > 18 month was an independent predictor of AF recurrence together with age > 62 years and female sex. In patients with persistent AF, the time from persistent AF showed to be significant predictor for AF recurrence.

CONCLUSIONS

In this multicenter analysis, time from first symptomatic AF episode > 18 months was a significant predictor of AF recurrence after CB PV isolation.

Cryoballoon ablation vs. antiarrhythmic drugs: first-line therapy for patients with paroxysmal atrial fibrillation

AIMS

Treatment guidelines for patients with atrial fibrillation (AF) suggest that patients should be managed with an antiarrhythmic drug (AAD) before undergoing catheter ablation (CA). This study evaluated whether pulmonary vein isolation employing cryoballoon CA is superior to AAD therapy for the prevention of atrial arrhythmia (AA) recurrence in rhythm control naive patients with paroxysmal AF (PAF).

METHODS AND RESULTS

A total of 218 treatment naive patients with symptomatic PAF were randomized (1 : 1) to cryoballoon CA (Arctic Front Advance, Medtronic) or AAD (Class I or III) and followed for 12 months. The primary endpoint was ≥1 episode of recurrent AA (AF, atrial flutter, or atrial tachycardia) >30 s after a prespecified 90-day blanking period. Secondary endpoints included the rate of serious adverse events (SAEs) and recurrence of symptomatic palpitations (evaluated via patient diaries). Freedom from AA was achieved in 82.2% of subjects in the cryoballoon arm and 67.6% of subjects in the AAD arm (HR = 0.48, P = 0.01). There were no group differences in the time-to-first (HR = 0.76, P = 0.28) or overall incidence [incidence rate ratio (IRR)=0.79, P = 0.28] of SAEs. The incidence rate of symptomatic palpitations was lower in the cryoballoon (7.61 days/year) compared with the AAD arm (18.96 days/year; IRR = 0.40, P < 0.001).

CONCLUSIONS

Cryoballoon CA was superior to AAD therapy, significantly reducing AA recurrence in treatment naive patients with PAF. Additionally, cryoballoon CA was associated with lower symptom recurrence and a similar rate of SAEs compared with AAD therapy.

Safety and efficacy of cryoballoon ablation for the treatment of paroxysmal and persistent AF in a real-world global setting: Results from the Cryo AF Global Registry

BACKGROUND

Cryoballoon ablation is a commonly used approach to treat patients with atrial fibrillation (AF).

OBJECTIVES

Report on the safety and efficacy of cryoballoon ablation for the treatment of AF in the largest global cohort of cryoablated patients prospectively studied within a single registry.

METHODS

The Cryo AF Global Registry is a prospective, multi-center registry. Patients with paroxysmal AF (PAF) or persistent AF (PsAF) were treated with the cryoballoon catheter according to routine practices at 93 sites across 36 countries. Primary efficacy endpoints included freedom from AF and freedom from AF/atrial flutter (AFL)/atrial tachycardia (AT) ≥30 seconds. The primary safety endpoint was serious device- or procedure-related adverse events over 12 month follow-up.

RESULTS

During this evaluation window, 2922 subjects completed an index cryoballoon procedure, and 1440 completed 12 month follow-up. The cohort was 61 ± 12 years of age, 36.3% female, and 78.7% PAF. Serious device- and procedure-related adverse event rates were 1.5% and 3.4%, respectively. Freedom from AF/AFL/AT after the 90 day blanking period was 86.4% (95% CI: 84.3%-88.3%) in patients with PAF and 70.9% (95% CI: 64.6%-76.4%) in patients with PsAF. Freedom from AF/AFL/AT in first-line PAF and PsAF was 90.0% (95% CI: 86.4%-92.7%) and 72.9% (95% CI: 58.6%-83.0%) at 12 months, respectively.

CONCLUSIONS

The Cryo Global AF Registry is the largest evaluation to demonstrate cryoablation is an efficient, safe, and effective treatment for patients with AF worldwide. Cryoablation was commonly used to treat patients prior to an AAD failure and may facilitate earlier therapy for patients on the AF disease continuum.

Longer diagnosis-to-ablation time is associated with recurrence of atrial fibrillation after catheter ablation-Systematic review and meta-analysis

BACKGROUND

Diagnosis-to-ablation time (DTAT) has been postulated to be one of the predictors of atrial fibrillation (AF) recurrence, and it is a "modifiable" risk factor unlike that of many electrocardiographic or echocardiographic parameters. This development may change our consideration for ablation. In this systematic review and meta-analysis, we aim to analyze the latest evidence on the importance of DTAT and whether they predict the AF recurrence after catheter ablation.

METHODS

We performed a comprehensive search on topics that assess diagnosis-to-ablation time (DTAT) and AF recurrence from inception up until August 2019 through PubMed, EuropePMC, Cochrane Central Database, and http://ClinicalTrials.gov.

RESULTS

There was a total of 3548 patients from six studies. Longer DTAT was associated with increased risk for AF recurrence in all studies included. Meta-analysis of these studies showed that DTAT had a hazard ratio (HR) of 1.19 [1.02, 1.39], P = .03; I 2: 92% for AF recurrence. Upon sensitivity analysis by removing a study, HR became 1.24 [1.16, 1.32], P < .001; I 2: 29%. Meta-analysis on DTAT time >3 years had HR 1.73 [1.54, 1.93], P < .001; I 2: 45% for the recurrence of AF. Upon subgroup analysis of data that compared >6 years to <1 year, the HR was 1.93 [1.62, 2.29], P < .001; I 2: 0%.

CONCLUSION

Longer DTAT time is associated with an increased risk of AF recurrence. Hence, determining management at the earliest possible moment to avoid delay is of utmost importance.

Diagnosis-to-Ablation Time and Recurrence of Atrial Fibrillation Following Catheter Ablation: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

The optimal timing of catheter ablation for atrial fibrillation (AF) in reference to the time of diagnosis is unknown. We sought to assess the impact of the duration between first diagnosis of AF and ablation, or diagnosis-to-ablation time (DAT), on AF recurrence following catheter ablation.

METHODS

We conducted a systematic electronic search for observational studies reporting the outcomes associated with catheter ablation for atrial fibrillation stratified by diagnosis-to-ablation time. The primary meta-analysis using a random effects model assessed AF recurrence stratified by DAT ≤1 year versus >1 year. A secondary analysis assessed outcomes stratified by DAT ≤3 years versus >3 years.

RESULTS

Of the 632 screened studies, 6 studies met inclusion criteria for a total of 4950 participants undergoing AF ablation for symptomatic AF. A shorter DAT ≤1 year was associated with a lower relative risk of AF recurrence compared with DAT >1 year (relative risk, 0.73 [95% CI, 0.65-0.82]; P<0.001). Heterogeneity was moderate (I²=51%). When excluding the one study consisting of only patients with persistent AF, the heterogeneity improved substantially (I²=0%, Cochran's Q P=0.55) with a similar estimate of effect (relative risk, 0.78 [95% CI, 0.71-0.85]; P<0.001).

CONCLUSIONS

Shorter duration between time of first AF diagnosis and AF ablation is associated with an increased likelihood of ablation procedural success. Additional study is required to confirm these results and to explore implementation of earlier catheter AF ablation and patient outcomes within the current AF care pathway. Visual Overview A visual overview is available for this article.

Association of Obesity Measures with Atrial Fibrillation Recurrence After Cryoablation in Patients with Paroxysmal Atrial Fibrillation

BACKGROUND Obesity increases the risk of atrial fibrillation (AF) recurrence after ablation. This study explored the relationship between various obesity indexes and risk of recurrence after cryoablation of paroxysmal AF (PAF). MATERIAL AND METHODS Our prospective study included 100 patients with PAF who underwent first cryoablation. Physical examination and fasting blood lipids levels were measured at baseline. Seven obesity indexes were determined: body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), waist-hip ratio (WHR), cardiometabolic index (CMI), lipid accumulation product (LAP), and body adiposity index (BAI). AF recurrence was confirmed by electrocardiograms and Holter monitor at follow-up visits after the initial 3-month blanking period. Receiver operating characteristic (ROC) curves were drawn to assess the abilities of obesity indicators in predicting AF recurrence. Multivariable Cox regression analysis was used to examine independent predictors of AF recurrence. RESULTS During a mean follow-up of 13.4 months, 31 patients (31.0%) had recurrent AF. Patients with recurrence had higher BMI, WC, WHtR, LAP, and BAI compared with those without recurrence. ROC analysis indicated the potential predictive value of BAI with an AUC of 0.657 (95% confidence interval [CI]: 0.534-0.779), followed by WC, WHtR, LAP, and BMI (all P<0.05). Diagnosis-to-ablation time (HR 1.034, 95% CI: 1.002-1.068), left atrial diameter (HR 1.147, 95% CI: 1.026-1.281), and WC (HR 1.026, 95% CI: 1.000-1.053) were independent predictive factors for AF recurrence after multivariable adjustment. CONCLUSIONS In this study population, WC appears to be a potential indicator for the prediction of recurrence in patients with PAF after cryoablation.