Funding Acknowledgements Type of funding sources: None. Background Cardiac computed tomography (CCT) is an essential tool for an efficient ablation for atrial fibrillation. 3D mapping guided ablation could also deliver sufficient results in the setting of cryoballoon ablation (CBA) with additional advantages regarding total patient radiation exposure, fluoroscopy and procedural time. Purpose To compare the 3D mapping with the Achieve® catheter versus the CCT on the procedural characteristics and acute outcome during CBA. Methods Consecutive patients who underwent CBA with the second-generation cryoballoon (CB) were retrospectively enrolled from a single centre registry. Baseline and procedural characteristics of patients with pre-procedural CCT (CT-Group) were compared to those with peri-procedural 3D mapping (Ensite PrecisionTM ) with the 1st generation Achieve® catheter (3D-Group). Results A total of 696 patients were enrolled, 327 (47%) in the CT-Group and 369 (53%) in the 3D-Group. Baseline characteristics were comparable between the two groups. Similar pulmonary vein (PV) anatomical variations were identified in both groups and all PVs were acutely isolated. The mean CB temperature (T) at 60s, the nadir T, the time to PV isolation, the T of isolation and the mean thaw time did not differ significantly. However, the total procedural and fluoroscopy time were significantly shorter as well as the dose area product was significantly less in the 3D-Group. Conclusion 3D mapping guided CBA using the Achieve® catheter is associated with significantly shorter fluoroscopy and procedural time and less patient radiation exposure. The anatomical acquisition of the PVs and the acute ablation outcome is non inferior to the CCT guided CBA. Procedural characteristics CT-Group n = 327 3D- Groupn = 369 p-value Paroxysmal AF 214 244 0.87 Total procedure time (min) 73.3 ± 23.1 65.1 ± 18.9 < 0.01 Fluoroscopy time (min) 14.9 ± 7.7 12.6 ± 7 0.02 DAP (Gy·cm2) 5924 ± 4991 4890 ± 3790 0.04 LCPV 37 41 1.00 RMPV 20 21 0.87 Mean T at 60s(oC) -41.9 ± 8.5 -40.6 ± 10.7 0.10 Mean nadir T(oC) -49.5 ± 6.4 -48.4 ± 7.8 0.18 Mean PVI time(s) 42.4 ± 26.3 38.1 ± 24.3 0.11 Mean PVI temperature(oC) -33.4 ± 11.6 -31.1 ± 22 0.16 Mean thaws time(s) 51.5 ± 20.5 51.8 ± 20.3 0.85
Introduction The purpose of this study was to analyze and compare the electrophysiological findings in redo radiofrequency (RF)-ablation of AF in a series of patients with durable PV isolation (PVI) and with PV reconnection after index procedure with the second-generation cryoballon (CB). Methods and results A total of 132 patients (81 males, 60.7 ± 12.4 years) who underwent CB-A for paroxysmal AF (PAF) were enrolled. Indication for the redo procedure was symptomatic (PAF) in 83 (63%) and persistent AF (PeAF) or persistent regular atrial tachycardia (RAT) in 49 (37%). Seventy-five (57%) patients presented a PV reconnection (PV group), whereas 57 (43%) no PV reconnection (non-PV group). The non-PV group exhibited significantly more atrial flutters and non-PV foci than the PV group after induction protocol (67% vs. 36%, p = 0.003 and 51% vs. 24% p = 0.002, respectively) (Table 1). Twenty-two (29.3%) patients of the PV group and 20 (35%) patients of the non-PV group had AF/RAT recurrence after a mean follow-up of 12.5 ± 8 months. The survival analysis demonstrated no statistical significance in recurrence between the two groups (log rank p = 0.358). In the cox regression analysis only the AF/RAT recurrence in the blanking period could predict independently an AF/RAT relapse. Conclusions AF/RAT recurrence in patients after CB-A with durable PVI is significantly associated to atrial flutters and non-PV foci. No statistically different success rate regarding AF/RAT freedom was detected between PV and non-PV Group after redo RF-CA. Table 1. Electrophysiological findings PV Groupn = 75 non-PV Groupn = 57 p-value PV trigger (n of patients) 75(100) 0(0) <0.001 LSPV 29 (39) 0 (0) <0.001 LIPV 15 (20) 0 (0) <0.001 RSPV 27 (36) 0 (0) <0.001 RIPV 33 (44) 0 (0) <0.001 Atrial flutters (n of patients) 27 (36) 38 (67) 0.003 Roof-flutter 13 (17) 34 (60) 0.0001 Peri-mitral-flutter 9 (12) 20 (35) 0.003 Right flutter 13 (17) 5 (9) 0.2 Non-PV foci (n of patients) 18 (24) 29 (51) 0.002 Categorical variables are expressed as absolute and percentage (in brackets). LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; PV, pulmonary vein; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein.
Funding Acknowledgements Type of funding sources: None. Background Absence of real-time PV isolation (PVI) by the Achieve catheter occurring in 15 to 40% of the veins during cryoballoon ablation (CBA) of atrial fibrillation (AF) raises doubt about adequate PVI. Purpose To determine whether veins without real-time PVI are predictive of long-term clinical outcome. Methods and Results 803 of 1000 consecutive AF patients (mean age 64±10 years, 68% males) treated with CBA were followed for 3 years. Clinical success defined as freedom of documented AF at 3 years was achieved in 65.3% of the patients. The cohort was divided in 4 groups according to the number of PVs with real-time PVI: all veins (N=252(31,4%)), 3 (N=255(31,8%)), 2 (N=159(19,8%)) and 0-1 vein (N=137(17,1)). 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 established predictors as 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). The highest clinical success was achieved in patients with real-time PVI in all veins (77.4%), gradually decreasing per increasing number of veins without 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), 83 out of 288 (28.8%) veins without real-time PVI were reconnected versus 99 out of the 430 (23.0%) veins with real-time PVI (p=0.08). Conclusion Veins without real-time PVI during CBA independently predict long-term AF recurrence with increasing AF recurrence per increase in veins without real-time PVI. A trend towards a higher reconnection rate in veins without real-time PVI suggest incomplete PVI or a less efficacious freeze resulting in less durable PVI.
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