The Absence of Real-time Pulmonary Vein Isolation During Cryoballoon Ablation is Associated with Atrial Fibrillation Recurrence and Pulmonary Vein Reconnection : Insights from the Middelheim-PVI Registry 2

Overview

Journal J Interv Card Electrophysiol

Publisher Springer

Date 2023 Apr 17

PMID 37067765

Authors

Y De Greef

D Sofianos

M Tijskens

B Schwagten

M Wolf

I Buysschaert

J P Abugattas

Affiliations

Soon will be listed here.

Abstract

Background: Absence of real-time pulmonary vein (PV) isolation (PVI) occurring in 15-40% of PVs during cryoballoon ablation (CBA) of atrial fibrillation (AF) raises doubt about adequate PVI. Aim of the present study is to determine whether real-time PVI during CBA is predictive of long-term clinical outcome and durability of PVI.

Methods: Eight hundred three AF patients (64 ± 10 years, 68% males) undergoing CBA were studied. The cohort was divided in 4 groups according to the number of PVs without real-time PVI: none (N = 252 [31.4%]), 1 (N = 255 [31.8%]), 2 (N = 159 [19.8%]), and 3-4 (N = 137 [17.1]).

Results: At 3 years, 279 (34.7%) patients had recurrence of AF of which 188 underwent repeat ablation. A vein without real-time PVI was associated with AF recurrence (HR = 1.275; 95% CI 1.134-1.433; p < 0.01), independent of persistent AF type (HR = 2.075; 95% CI 1.584-2.738; p < 0.01), left atrial diameter (HR = 1.050; 95% CI 1.028-1.072; p < 0.01), and diagnosis-to-ablation time (HR = 1.002; 95% CI 1.000-1.005; p = 0.04). Highest success was achieved with present real-time PVI in all veins (77.4%), gradually decreasing per increasing number of absent real-time PVI: 66.3% for 1 vein, 58.5% for 2, and 48.9% for 3-4 veins (p < 0.001). At repeat ablation (N = 188), PV reconnection was seen in 99/430 (23.0%) versus 83/288 (28.8%) veins with and without real-time PVI, respectively (p = 0.08). Right inferior PVs (RIPVs) with real-time PVI were less reconnected than RIPVs without real-time PVI: 29.7% versus 43.7% (p = 0.047).

Conclusion: The absence of real-time PVI during CBA independently predicts AF recurrence with a 30% gradual decrease in outcome per increase in veins without real-time PVI. Real-time PVI is particularly important for the RIPV to achieve durable PVI.

Citing Articles

Validation of a machine learning algorithm to identify pulmonary vein isolation during ablation procedures for the treatment of atrial fibrillation: results of the PVISION study.

De Pooter J, Timmers L, Boveda S, Combes S, Knecht S, Almorad A Europace. 2024; 26(5).

PMID: 38682165 PMC: 11089576. DOI: 10.1093/europace/euae116.

Adding Electroanatomical Mapping to Cryoballoon Pulmonary Vein Isolation Improves 1-Year Clinical Outcome and Durability of Pulmonary Vein Isolation: A Propensity Score-Matched Analysis.

Tijskens M, Abugattas J, Thoen H, Strazdas A, Schwagten B, Wolf M J Cardiovasc Dev Dis. 2024; 11(2).

PMID: 38392271 PMC: 10889252. DOI: 10.3390/jcdd11020057.

References

Heeger C, Wissner E, Knoll M, Knoop B, Reissmann B, Mathew S . Three-Year Clinical Outcome After 2nd-Generation Cryoballoon-Based Pulmonary Vein Isolation for the Treatment of Paroxysmal and Persistent Atrial Fibrillation　- A 2-Center Experience. Circ J. 2017; 81(7):974-980. DOI: 10.1253/circj.CJ-16-1334. View

Furnkranz A, Bordignon S, Schmidt B, Gunawardene M, Schulte-Hahn B, Urban V . Improved procedural efficacy of pulmonary vein isolation using the novel second-generation cryoballoon. J Cardiovasc Electrophysiol. 2013; 24(5):492-7. DOI: 10.1111/jce.12082. View

Boveda S, Providencia R, Albenque J, Combes N, Combes S, Hireche H . Real-time assessment of pulmonary vein disconnection during cryoablation of atrial fibrillation: can it be 'achieved' in almost all cases?. Europace. 2013; 16(6):826-33. DOI: 10.1093/europace/eut366. View

Yokoyama K, Tokuda M, Matsuo S, Isogai R, Tokutake K, Kato M . Pulmonary vein re-mapping after cryoballoon ablation for atrial fibrillation. Europace. 2017; 20(6):943-948. DOI: 10.1093/europace/eux129. View

Conte G, Soejima K, de Asmundis C, Chierchia G, Badini M, Miwa Y . Value of high-resolution mapping in optimizing cryoballoon ablation of atrial fibrillation. Int J Cardiol. 2018; 270:136-142. DOI: 10.1016/j.ijcard.2018.05.135. View

Verma A, Kilicaslan F, Pisano E, Marrouche N, Fanelli R, Brachmann J . Response of atrial fibrillation to pulmonary vein antrum isolation is directly related to resumption and delay of pulmonary vein conduction. Circulation. 2005; 112(5):627-35. DOI: 10.1161/CIRCULATIONAHA.104.533190. View

Hindricks G, Potpara T, Dagres N, Arbelo E, Bax J, Blomstrom-Lundqvist C . 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the.... Eur Heart J. 2020; 42(5):373-498. DOI: 10.1093/eurheartj/ehaa612. View

Stroker E, De Greef Y, Schwagten B, Kupics K, Coutino H, Takarada K . Over-the-needle trans-septal access using the cryoballoon delivery sheath and dilator in atrial fibrillation ablation. Pacing Clin Electrophysiol. 2019; 42(7):868-873. DOI: 10.1111/pace.13709. View

Calkins H, Hindricks G, Cappato R, Kim Y, Saad E, Aguinaga L . 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017; 14(10):e275-e444. PMC: 6019327. DOI: 10.1016/j.hrthm.2017.05.012. View

10.

Aryana A, Mugnai G, Singh S, Pujara D, de Asmundis C, Singh S . Procedural and biophysical indicators of durable pulmonary vein isolation during cryoballoon ablation of atrial fibrillation. Heart Rhythm. 2015; 13(2):424-32. DOI: 10.1016/j.hrthm.2015.10.033. View

11.

Tagawa M, Higuchi K, Chinushi M, Washizuka T, Ushiki T, Ishihara N . Myocardium extending from the left atrium onto the pulmonary veins: a comparison between subjects with and without atrial fibrillation. Pacing Clin Electrophysiol. 2001; 24(10):1459-63. DOI: 10.1046/j.1460-9592.2001.01459.x. View

12.

Mugnai G, de Asmundis C, Hunuk B, Stroker E, Moran D, Hacioglu E . Improved visualisation of real-time recordings during third generation cryoballoon ablation: a comparison between the novel short-tip and the second generation device. J Interv Card Electrophysiol. 2016; 46(3):307-14. DOI: 10.1007/s10840-016-0114-9. View

13.

Moltrasio M, Sicuso R, Fassini G, Riva S, Tundo F, Dello Russo A . Acute outcome after a single cryoballoon ablation: Comparison between Arctic Front Advance and Arctic Front Advance PRO. Pacing Clin Electrophysiol. 2019; 42(7):890-896. DOI: 10.1111/pace.13718. View

14.

Matsuda Y, Masuda M, Asai M, Iida O, Okamoto S, Ishihara T . A decapolar 25-mm-diameter circular mapping catheter with improved detection of pulmonary vein potential disappearance in cryoballoon ablation. J Arrhythm. 2019; 35(3):535-541. PMC: 6595353. DOI: 10.1002/joa3.12192. View

15.

Conte G, Soejima K, de Asmundis C, Bruno J, Cattaneo F, Chierchia G . High-density mapping in patients undergoing ablation of atrial fibrillation with the fourth-generation cryoballoon and the new spiral mapping catheter. Europace. 2020; 22(11):1653-1658. DOI: 10.1093/europace/euaa160. View

16.

Iacopino S, Mugnai G, Takarada K, Paparella G, Stroker E, De Regibus V . Second-generation cryoballoon ablation without the use of real-time recordings: A novel strategy based on a temperature-guided approach to ablation. Heart Rhythm. 2016; 14(3):322-328. DOI: 10.1016/j.hrthm.2016.11.023. View

17.

Paparella G, Iacopino S, Osorio T, Abugattas de Torres J, Stroker E, Sieira J . Temperature-guided ablation with the second-generation cryoballoon for paroxysmal atrial fibrillation: 3-year follow-up in a multicenter experience. J Interv Card Electrophysiol. 2020; 61(1):95-104. DOI: 10.1007/s10840-020-00770-6. View

18.

Prochnau D, von Knorre K, Figulla H, Schulze P, Surber R . Efficacy of temperature-guided cryoballoon ablation without using real-time recordings - 12-Month follow-up. Int J Cardiol Heart Vasc. 2018; 21:50-55. PMC: 6174823. DOI: 10.1016/j.ijcha.2018.09.009. View

19.

Martins R, Nicolas A, Galand V, Pichard C, Behar N, Cherel C . The challenging right inferior pulmonary vein: A systematic approach for successful cryoballoon ablation. Arch Cardiovasc Dis. 2019; 112(8-9):502-511. DOI: 10.1016/j.acvd.2019.05.006. View

20.

Nakagawa H, Aoyama H, Beckman K, Po S, Wu R, Lockwood D . Relation between pulmonary vein firing and extent of left atrial-pulmonary vein connection in patients with atrial fibrillation. Circulation. 2004; 109(12):1523-9. DOI: 10.1161/01.CIR.0000121745.13435.E0. View