Cryoballoon ablation for persistent atrial fibrillation in patients without left atrial fibrosis

Abstract

Introduction: The role of cryoballoon (CB) pulmonary vein isolation (PVI) for patients with persistent atrial fibrillation (AF) is controversial, since long-term success can be poor. We performed left atrial voltage mapping before CB PVI and determined AF-free survival depending on the extent of low-voltage areas (LVAs). Methods and Results:We consecutively enrolled 60 patients with persistent AF (average age, 60.6 ± 12.9 years; CHA 2 DS 2 VASc score, 2.3 ± 1.6; and left atrial size 46.0 ± 5.2 mm) who were planned for CB PVI. Before ablation, we performed left atrial voltage mapping (Abbott EnSite Precision or Velocity). LVAs were defined if local bipolar signal amplitudes were less than 0.5 mV during sinus rhythm. Thirty-seven patients did not show significant LVAs (<10%), while 12 patients had LVAs between 10% and 30% and 11 patients showed substantial LVAs greater than 30% of the left atrial area. CB PVI could be successfully performed in all patients. A 7-day holter monitoring was obtained 3, 6, and 12 months after ablation. After a 12-month follow-up time, 83.8% of patients without LVAs (<10%) were free of atrial fibrillation, while 50.0% of patients with 10% to 30% LVAs and 9.1% of patients with LVAs more than 30% had stable sinus rhythm. The degree of atrial fibrosis correlated with the risk of AF recurrence. Conclusion:In patients with persistent AF undergoing CB PVI, the extent of left atrial LVAs predicts an AF-free survival. CB PVI seems to be a highly effective treatment for patients with persistent AF without atrial fibrosis.

Effectiveness of Radiofrequency Catheter Ablation Using Ablation Index Versus Second Generation Cryoballoon in the Treatment of Persistent Atrial Fibrillation: A Matching-Adjusted Indirect Comparison

“…1). Of a total of 325 citations identified for full-text review, 4 were eligible for inclusion in the present analysis [4,[18][19][20]. Reasons for exclusion included study design (e.g., retrospective studies), population (e.g., paroxysmal AF, long-standing PsAF), irrelevant intervention or comparator, or if the study did not report the outcomes of interest.…”

“…A total of 389 patients with PsAF were pooled from four CB trials [4,[18][19][20]. The mean (SD) age of the pooled CB cohort was 63.1 (10.2) years.…”

Conversion of atrial fibrillation to sinus rhythm during cryoballoon ablation: A favorable and not unusual phenomenon during second‐generation cryoballoon pulmonary vein isolation

“…The importance of LA dimensions in the settings of CB‐A has been recently confirmed by Akkaya et al, as they showed that left atrial area >21 cm 2 was a significant predictor of recurrence in a population of 101 patients undergoing CB‐A with second‐generation CB. Furthermore, in a recent work from Gramlich et al, the degree of atrial fibrosis was proved to correlate with the risk of AF recurrence at 1 year follow‐up after CB‐A in 60 patients with persistent AF, therefore stressing the relevance of possible residual substrate areas besides PVs in those patients with a large extent of low‐voltage areas and more generally of the LA disease.…”

“…dergoing CB-A with second-generation CB. Furthermore, in a recent work from Gramlich et al,34 the degree of atrial fibrosis was proved to correlate with the risk of AF recurrence at 1 year follow-up after CB-A in 60 patients with persistent AF, therefore stressing the relevance of possible residual substrate areas besides PVs in those patients with a large extent of low-voltage areas and more generally of the LA disease.Interestingly, most of episodes of restoration of SR (69.8%) in our case group occurred while performing right PVs cryo-applications.Despite the frequent localization of focal AF triggers in the RSPV35 and the central role of the cryo-applications on the right-side PVs in modifying the cardiac autonomic nervous system,36,37 the electrophysiological and clinical significance of this observation remains unclear; moreover, since right PVs cryo-applications are the ones performed in the second half of the procedure, some role and/or a cumulative effect of previous cryo-applications on the results described cannot be excluded. Since the area targeted by CB is wide and antral,38 the extent of the lesion created by the cryo-application may also involve other structures of the LA which may have a role in maintaining AF.…”

Cool enough? Lessons learned from cryoballoon‐guided catheter ablation for atrial fibrillation in young adults

“…LA fibrosis, a hallmark of atrial remodeling, has been discriminated as a relevant predictor of AF recurrence after successful catheter ablation 25 . In this context, the recent study by Gramlich et al 26 demonstrated that the presence of LA low‐voltage areas significantly affected the success of CB‐guided PVI.…”