Pulmonary Vein Isolation in Elderly Patients ≥ 75 Years: A Propensity Score-Matched Analysis With Focus on Differences Among Atrial Fibrillation Types

BACKGROUND

Age is a major risk factor for development of atrial fibrillation (AF) and associated with increased recurrence rates in the setting of rhythm control. Current data tend to support catheter ablation in elderly patients, but uncertainties exist regarding efficacy and safety of ablation in elderly patients.

METHODS

This was a prospective single-centre observational study with propensity score matching (PSM) to investigate the influence of age on efficacy and safety of cryoballoon ablation (CBA) stratified by age (< 75 years vs ≥ 75 years) and AF phenotype (paroxysmal vs persistent). Primary efficacy endpoint was recurrence of atrial arrhythmia after a 90-day blanking period. Safety endpoints were death, stroke, or procedure-associated complications.

RESULTS

Consecutive patients (n = 953) underwent CBA for first-time AF ablation. Median follow-up was 18 months. By means of PSM, 268 matches were formed. At 1 year, primary efficacy endpoint occurred in 22.4% of young vs 33.2% of elderly patients, including both AF phenotypes (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.47-0.90; P = 0.01). AF relapse occurred in 19.7% of young vs 28.5% of elderly patients with paroxysmal (HR, 0.63; 95% CI, 0.40-0.99; P = 0.046) compared with 25.9% (30 of 116, young) vs 38.8% (45 of 116, elderly) patients with persistent AF (HR, 0.62; 95% CI, 0.39-0.97; P = 0.038). No difference was observed regarding the incidence of safety endpoints between young and elderly patients (P = 0.38).

CONCLUSIONS

CBA is associated with higher recurrence rates in elderly (≥ 75 years) than in younger patients, with highest recurrence rates in elderly patients with persistent AF.

Zero-fluoro atrioventricular-nodal reentrant tachycardia ablation

BACKGROUND

Atrioventricular-nodal reentrant tachycardia (AVNRT) is a common supraventricular tachycardia, particularly in younger patients. The treatment of choice is radiofrequency catheter ablation (RFCA), traditionally necessitating ionizing radiation for catheter guidance.

OBJECTIVE

The authors aimed to demonstrate the feasibility and safety of zero-fluoroscopy RFCA of AVNRT using EnSite™ NavX™ as a three-dimensional (3D) electroanatomical mapping system (EAM).

METHODS

The authors retrospectively analyzed 68 patients that underwent AVNRT-RFCA. One group was a priori allocated to conventional fluoroscopy mapping (convFluoro, n = 30). In 38 cases, the electrophysiologist chose to use 3D-EAM for ablation. Of these patients, 20 could be ablated without fluoroscopy use (zeroFluoro). In 18 cases that were initially intended as 3D-EAM, additional fluoroscopy use was necessary due to difficult anatomic conditions (convertedFluoro). Procedure duration, fluoroscopy duration and dose, as well as complications were analyzed.

RESULTS

Procedure duration was similar for the convFluoro and zeroFluoro groups (74 ± 24 min vs. 80 ± 26 min, p = ns). The convertedFluoro group showed longer procedure duration compared to the convFluoro group (94 ± 30 min vs. 74 ± 24 min, p < 0.05). The use of 3D-EAM significantly reduced fluoroscopy duration comparing the convFluoro with the convertedFluoro group (12 ± 9 min vs. 7 ± 6 min, p < 0.05). The difference in fluoroscopy dose between convFluoro and convertedFluoro did not reach significance (169 ± 166 cGycm2 vs. 134 ± 137 cGycm2, p = ns). In zeroFluoro cases, no radiation was used at all. 3D-EAM-guided RFCA was primarily successful in all patients. Overall, there were only few minor complications in the different groups. No major complications occurred.

CONCLUSION

Zero-fluoro RFCA in patients with AVNRT is feasible and safe. 3D-EAM can reduce radiation exposure in the majority of patients without prolonging procedure duration or increasing complications.

Cryoballoon pulmonary vein isolation for atrial fibrillation in obese patients: A non-inferiority analysis

Background

Patients with obesity are at higher risk of developing atrial fibrillation (AF) and benefit from radiofrequency ablation. Potentially, cryoballoon ablation (CBA) may be equally effective and safe in such patients.

Methods

We conducted a prospective, single-center study to investigate whether CBA for pulmonary vein isolation is as effective and safe in obese patients as it is in non-obese controls. Primary efficacy endpoint was recurrence of AF, atrial flutter or atrial tachycardia after a 90-day blanking period. Safety endpoints were death, stroke or procedure-associated complications. Conduction of a subgroup analysis regarding the impact of additional diabetes was predefined in case the primary efficacy endpoint was met. The study was event driven and powered for noninferiority.

Results

A total of 949 patients underwent CBA (251 obese with mean body-mass-index 33.5 ± 3 kg/m2 and 698 non-obese with mean body-mass-index 25.3 ± 3 kg/m2) during a 5-year recruitment period. Median follow-up was 15 months. The primary efficacy endpoint occurred in 78/251 obese and 247/698 non-obese patients (12-months Kaplan-Meier event-rate estimates, hazard ratio 0.79; 95% confidence interval [CI], 0.58 to 1.07; log-rank P = 0.0002 for noninferiority). No differences were observed in safety end point occurrence (P = 0.78). The occurrence of primary efficacy end point was found to be unaffected by the presence of diabetes in the prespecified subgroup analysis (log-rank P = 0.57).

Conclusion

CBA is effective and safe in obese and DM patients. Weighing the high cardiovascular risk of obese patients against a reduction of cardiovascular events by early rhythm control, CBA should be offered to this patient population.

Process optimization for atrial fibrillation ablation

AIMS

In the light of an increasing prevalence of atrial fibrillation (AF) and growing evidence for the superiority of early invasive rhythm control, the demand for ablation therapy is rising. Accordingly, ablation centres will have to maximize their capacity by either adding electrophysiology laboratory resources or optimizing process management. In order to optimize process management, we applied "Lean Six Sigma" method to a single ablation center. We compared procedural parameters, acute efficacy and safety of cryoballoon pulmonary vein isolation (cryoPVI) before and after modifications.

METHODS AND RESULTS

Patients (n = 713) undergoing cryoPVI (108 before and 605 after process optimization) were analysed. Within 3 years of process optimization, electrophysiology laboratory occupancy time (150.7 ± 44.4 vs. 94 ± 22.1 min, P < 0.001), procedure time (84.5 ± 21-47.4 ± 12 min, P < 0.001), left-atrial dwell time (53.9 ± 18.4-31.9 ± 9.9 min, P < 0.001), and fluoroscopy time (15.8 ± 5.1 vs. 6.2 ± 2.8 min, P < 0.001) decreased. Contrast dye use (116 ± 35 vs. 27 ± 15 mL, P < 0.001) and radiation dose (893 ± 1078 vs. 253 ± 249 cGy cm2, P < 0.001) were reduced by ∼77 and ∼72%, respectively. There was no difference in safety endpoint occurrence (3.7 vs. 1.5%, P = 0.11).

CONCLUSION

The process optimization of cryoPVI for AF therapy using the 'Lean Six Sigma' method significantly increases efficiency without compromising patient safety.

Persistent Atrial Fibrillation in Elderly Patients: Limited Efficacy of Pulmonary Vein Isolation

(1) Background: Cryoballoon pulmonary vein isolation (cryoPVI) is established for symptomatic paroxysmal atrial fibrillation (AF) treatment, but its value in persistent AF is less clear. In particular, limited data are available on its efficacy in elderly patients (≥75 years) with persistent AF. Age is an important modifier of AF progression and represents a risk-factor for AF recurrence. (2) Methods: Prospective, single-center observational study to evaluate the impact of age on efficacy and safety of cryoPVI in elderly patients. Primary efficacy endpoint was symptomatic AF recurrence after 90-day blanking period. Primary safety endpoints were death from any cause, procedure-associated complications or stroke/transient ischemic attack. Median follow-up was 17 months (range 3−24). (3) Results: We included 268 patients with persistent AF (94 ≥ 75 years of age). Multivariate Cox regression analysis identified age as the only independent factor influencing AF recurrence in the overall cohort (p = 0.006). To minimize confounding bias in efficacy and safety analysis of cryoPVI, we matched younger and elderly patients with respect to baseline characteristics. At 24 months, primary efficacy endpoint occurred in 13/69 patients <75 years and 31/69 patients ≥75 years of age (24 months Kaplan−Meier event-rate estimates, HR 0.34; 95% CI, 0.19 to 0.62; log-rank p = 0.0004). No differences were observed in the occurrence of safety end points. (4) Conclusions: Elderly (≥75 years) patients with persistent AF undergoing cryoPVI had an approximately threefold higher risk of symptomatic AF recurrence than matched younger patients. Accordingly, other treatment modalities may be evaluated in this population.

Efficacy of cryoballoon ablation for atrial fibrillation in a geriatric population

Background

Cryoballoon pulmonary vein isolation (cryoPVI) is well-established for paroxysmal atrial fibrillation (AF) but its value in persistent AF is less clear. In particular, its efficacy in cardiogeriatric patients (≥75 years) is unknown. Age represents an important modifier of AF progression and is a risk-factor for AF recurrence.

Methods

We conducted a prospective, single-center study to analyze efficacy and safety of cryoPVI in cardiogeriatric patients stratified according to AF entity. Maximum follow-up was 24 months. Efficacy endpoint was symptomatic AF relapse after 90-day blanking period.

Results

We included 668 patients. Of these 218 were ≥75 years old. Paroxysmal AF was present in 400 and persistent AF in 268 patients. By means of cox-regression analysis we found age as the only independent factor influencing AF recurrence in the overall cohort (P=0.034). This effect was carried by patients with persistent AF (P=0.006). At 24 months, the recurrence rate was highest in patients with persistent AF and age ≥75 years (57%; P=0.0004).

Conclusion

Cardiogeriatric patients with persistent AF undergoing cryoPVI had higher rates of AF recurrence compared to elderly patients with paroxysmal AF or younger patients. Against this background we assume, that pulmonary-vein dependent AF may be less frequently encountered among patients ≥75 years with persistent AF.

Funding Acknowledgement

Type of funding sources: None.

Zero-fluoro AVNRT ablation

Background

Atrioventricular-nodal reentry tachycardia (AVNRT) is a common supraventricular tachycardia, particularly in younger patients. First-line therapy in symptomatic patients is radiofrequency catheter ablation (RFCA). Catheter placement and ablation are typically performed by fluoroscopy guidance implying a non-negligible exposure of ionizing radiation for patient and laboratory personnel.

Purpose

We aimed to demonstrate feasibility and safety of AVNRT ablation using 3D-electroanatomic mapping (3D-EAM) as sole and additional means of catheter guidance compared to conventional fluoroscopic positioning. Endpoints were: procedure duration, fluoroscopy duration, radiation dose and occurrence of any complication.

Methods

We retrospectively included consecutive patients (n=68, mean age 55±18 years) who underwent RFCA of AVNRT between 01/2020 and 12/2021 in our hospital. One group was a priori allocated to conventional fluoroscopy mapping (convFluoro, n=30), the other procedures were performed under 3D-EAM using Ensite NavX (NavX). From the latter, slow-pathway RFCA could be performed without any fluoroscopy (zeroFluoro) in 20 patients, in 18 cases additionally fluoroscopy was used due to difficult anatomic conditions (NavX+Fluoro). Success of RFCA was defined as slow-pathway elimination.

Results

There was no significant difference in procedure duration between the convFluoro and overall NavX group (74±24 min vs. 87±29 min, P=NS). However, NavX+Fluoro group (comprising more complicated cases) had longer procedure duration compared to convFluoro group (94±30 min vs. 74±24 min, p&lt;0.05). The use of 3D-EAM significantly reduced fluoroscopy duration comparing convFluoro with NavX+Fluoro (12±9 min vs. 7±6 min, p&lt;0.05) and convFluoro with overall NavX-group (12±9 min vs. 3±5 min, p&lt;0.0001). Likewise, radiation dose was significantly decreased by means of 3D-EAM (NavX: 60±113 cG cm2 vs. convFluoro: 169±166 cG cm2, p&lt;0.01). 3D-EAM guided RFCA was successful in all patients (100%), success rate in convFluoro-group was 87% (P=NS). Minor complications occurred in two cases (7%) in the convFluoro-group and 4 cases (11%) in the NavX-group (P=NS). No severe complication, such as pericardial effusion or permanent AV-block occurred in any group.

Conclusion

Zero-fluoroscopy 3D-EAM-guided RFCA in patients with AVNRT is feasible and safe. Without prolonging procedure duration, 3D-EAM can reduce fluoroscopy duration leading to lower radiation exposure and making electrophysiological study safer for laboratory staff and patients.

Funding Acknowledgement

Type of funding sources: None.

Cryoballoon ablation in obese patients: it is worth it, let us work it

Background

Obesity is a major risk factor for atrial fibrillation (AF) development and of increasing prevalence in western countries. Safe and effective treatment methods for obese patients with AF are therefore important. Cryoballoon pulmonary vein isolation (CryoPVI) is a well-established therapy for symptomatic AF but data regarding obese patients are lacking.

Objective

To prospectively compare efficacy, safety and periprocedural parameters of CPVI in normal-weight and obese (Body-Mass-Index (BMI) ≥30kg/m2) patients.

Methods

We analyzed consecutive patients who underwent CryoPVI in a single-center cohort between 2018 and 2020. CryoPVI was performed in a standardized fashion. Follow-up was performed at 3, 6, 12, 18 and 24 months after CryoPVI. Endpoints were: symptomatic AF relapse for efficacy and bleeding, phrenic nerve injury, stroke or death for safety. Periprocedureal parameters were observed.

Results

We included 464 patients into the analysis, of these 331 patients had normal BMI (mean BMI 25.5±2.8 kg/m2, age 70±10 years, CHA2DS2-VASc 2.7±1.5, 56% male) while 133 patients (28.7%) suffered from obesity (mean BMI 33.2 kg/m2, age 67±9 years, CHA2DS2-VASc 2.7±1.4, 55% male). After 24 months freedom from AF relapse was similar for normal-weight and obese patients (58.8% vs. 61%, P=0.78, Figure 1A). Primary safety end point occurred in form of pericardial effusion or phrenic nerve injury in five patients with normal BMI (1.5%) and none obesity group. No deaths or strokes were observed in either group. Compared with control left-atrial dwell time (39.7±14.6 min vs. 44.8±18.7 min, P=0.002, fluoroscopy time (7.3±3.6 min vs. 8.3±4.1 min, P=0.013), contrast dye use (64.6±34.3 ml vs. 74.5±39.5 ml, P=0.009), and radiation dose (224.8±164.2 cGy·cm2 vs. 533.3±655.6 cGy·cm2, P&lt;0.001) were significantly higher in obese patients (Figure 1B–E).

Conclusion

CryoPVI is safe and effective in obese patients but achievement of PVI is associated with longer procedure times, higher radiation exposure and contrast dye use.

Funding Acknowledgement

Type of funding sources: None.

Electrical cardioversion during cryoballoon pulmonary vein isolation predicts long-term ablation success in persistent atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Cryoballoon pulmonary vein isolation (cryoPVI) is an established option for treatment of atrial fibrillation (AF) but many periprocedural events influencing long-term outcome and procedural safety of ablation remain unclear. In radiofrequency ablation studies, failure to convert to sinus rhythm and electrical cardioversion (ECV) have been associated with increased recurrence rates. In this context, the influence of ECV during cryoPVI on long-term ablation efficacy is unclear.

Objective

A prospective comparison of AF recurrence after cryoballoon ablation in patients who were in AF or atrial tachycardia at the beginning of cryoPVI requiring ECV during procedure with patients who underwent ablation therapy without ECV.

Methods

We analyzed consecutive patients who underwent cryoPVI in a single-center cohort between 2018 and 2020. Follow-up was performed at 3, 6, 12, 18 and 24 months after ablation. Primary endpoints were: symptomatic AF recurrence for efficacy and bleeding, phrenic nerve injury, stroke or death for safety.

Results

472 consecutive patients who underwent ablation in a single-center cohort were analysed. Mean follow-up time was 15 months. In 195 patients (74 paroxysmal AF vs. 121 persistent AF, age 69 ± 10 years, 57% male, CHA2DS2-VASc 2.6 ± 1.4) at least one ECV was performed following ablation, while no cardioversion was necessary in 277 patients (214 paroxysmal AF vs. 63 persistent AF, age 69 ± 10 years, 55% male, CHA2DS2-VASc 2.7 ± 1.5). After 24 months, primary efficacy endpoint occurrence was significantly higher in persistent AF requiring cardioversion during procedure than for persistent AF without cardioversion and paroxysmal AF with/ without cardioversion (56.1 % vs. 31.2%, 33.6%, 32.9%, log-rank p = 0.009, figure). Primary safety endpoint occurred in form of pericardial effusion or transient phrenic nerve injury in two patients in cardioversion group (1.0%) and three patients without cardioversion (1.1%). No deaths or strokes were observed in either group. Total procedure duration (55.6 ± 17min vs. 57.7 ± 15.9min, P = 0.17) and left-atrial dwell time (39.7 ± 14.9min vs. 42 ± 15.6min, P = 0.11) were similar.

Conclusion

In patients with persistent AF, the need for ECV during cryoPVI predicts a poorer long-term outcome during 2-year follow-up. Future studies should focus on this specific patient population. Abstract Figure.