Background
Additional benefit of cryoballoon left atrial roof line ablation (CB‐RA) beyond cryoballoon pulmonary vein isolation (CB‐PVI) is suggested in patients with persistent atrial fibrillation (PsAF). We sought to investigate the feasibility of CB‐RA for PsAF and to determine the ablation area.
Methods and Results
Fifty‐three PsAF patients (67[58.5–75.5] years, 36 men, 11 longstanding PsAF) underwent CB‐PVI. Subsequently, 44(83.0%) out of 53 patients underwent additional CB‐RA. Voltage maps were created in all patients with a high‐resolution mapping system. The total number and duration of CB‐RAs were 3.9 ± 0.7 and 468 ± 84 s. LA roof areas were complete low voltage areas (LVAs) /scar in 37/44(84.1%) patients (“complete roof modification”). The normal LA posterior wall (LAPW) voltage area was 6.1(4.1–8.4) cm2, and the %LAPW isolation area was 61.0(47.2–71.7)%. The %LAPW isolation area was significantly greater in CB‐RA patients than those without (64.0[54.2–73.2] vs. 45.0[39.5–50.5]%, p = .041) despite significantly larger LAs in the former group. The %LAPW isolation area was significantly greater in patients with transverse LA diameters < 45 mm than those ≥ 45 mm (p < .0001). The single procedure 1‐year AF freedom was 87.4% (22.5% on antiarrhythmic drug) and tended to be higher in CB‐RA patients than those without. Among the 44 CB‐RA patients, it was significantly higher in patients with a complete roof modification than those without (94.4% vs. 75.0%, p = .0049). One CB‐RA patient experienced a delayed cardiac tamponade requiring drainage at 4‐months post‐procedure.
Conclusions
CB‐RA significantly expanded the LAPW isolation area, and a complete roof modification resulted in a high arrhythmia freedom in PsAF patients.
Background: The utility of pressure waveform analyses to assess pulmonary vein (PV) occlusions has been reported in cryoballoon PV isolation (CB‐PVI) using first‐generation CBs. This prospective randomized study compared the procedural and clinical outcomes of pressure‐guided and conventional CB‐PVI.
Methods and Results: Sixty patients with paroxysmal atrial fibrillation underwent CB‐PVI with 28‐mm second‐generation CBs. PV occlusions were assessed either by real‐time pressure waveforms without contrast utilization (pressure‐guided group) or contrast injections (conventional group) and randomly assigned. Before the randomization, 24 patients underwent pressure‐guided CB‐PVIs. In the derivation study, a vein occlusion was obtained in 88/96 (91.7%) PVs among which 86 (97.7%) were successfully isolated by the application. In the validation study, the nadir balloon temperature and total freezing time did not significantly differ per PV between the two groups. The positive predictive value of the vein occlusion for predicting successful acute isolations was similar (93 of 103 [90.2%] and 89 of 98 [90.8%] PVs; P = 1.000), but the negative predictive value was significantly higher in pressure‐guided than angiographical occlusions (14 of 17 [82.3%] vs 7 of 22 [31.8%]; P = .003). Both the procedure (57.7 ± 14.2 vs 62.6 ± 15.8 minutes; P = .526) and fluoroscopic times (16.3 ± 6.4 vs 20.1 ± 6.1; P = .732) were similar between the two groups, however, the fluoroscopy dose (130.6 ± 97.7 vs 353.2 ± 231.4 mGy; P < .001) and contrast volume used (0 vs 17.5 ± 7.7 mL; P < .001) were significantly smaller in the pressure‐guided than conventional group. During 27.8 (5‐39) months of follow‐up, the single procedure arrhythmia freedom was similar between the two groups (P = .438).
Conclusions: Pressure‐guided second‐generation CB‐PVIs were similarly effective and as safe as conventional CB‐PVIs. This technique required no contrast utilization and significantly reduced radiation exposure more than conventional CB‐PVIs.
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