Five‐year experience with pulmonary vein isolation using the second‐generation cryoballoon for treatment of persistent atrial fibrillation

Akkaya, Ersan; Berkowitsch, Alexander; Zaltsberg, Sergej; Greiß, Harald; Hamm, Christian W.; Sperzel, Johannes; Neumann, Thomas; Kuniss, Malte

doi:10.1111/jce.13743

Cited by 11 publications

(18 citation statements)

References 23 publications

(62 reference statements)

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“…In accordance with previous findings, LA diameter, duration of AF history, and early recurrence were found to be independent predictors of late recurrence in our current study. While early recurrence, LA diameter, and duration of AF history were found as the predictors of late ATa recurrence in paroxysmal AF patients, only LA diameter was found to be associated with late recurrence in persistent AF patients of our study population, which were also consistent in very recent study findings …”

Section: Discussionsupporting

confidence: 93%

“…Furthermore, in the multicenter Italian Clinical Service 1STOP project, Tondo et al reported that the AF‐free survival was 63.9% at 12 months and 51.5% at 18 months in 486 nonparoxysmal AF patients. Furthermore, Akkaya et al reported a 67.9% ATa‐free success rate in 102 persistent AF patients with a 5‐year follow‐up. The difference in regard to success rates in such patient groups between center‐based studies most commonly depends on the study population, patient characteristics, and operator experience rather than center experience for CB ablation, and follow‐up methodology.…”

Section: Discussionmentioning

confidence: 99%

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Long‐term outcomes of pulmonary vein isolation using second‐generation cryoballoon during atrial fibrillation ablation

Canpolat

Koçyiğit²,

Yalçın

et al. 2019

Pacing Clinical Electrophis

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Background: Currently available second-generation cryoballoon (CB2) is accepted as an effective and safe tool for pulmonary vein isolation (PVI). Although much more data exist about 1-year outcomes of CB2 ablation, data on long-term outcomes are scarce. Objective:We aimed to assess the long-term outcomes of PVI using CB2 in a large-scale symptomatic atrial fibrillation (AF) population at our tertiary referral center. Methods:In this nonrandomized prospective observational study, a total of 486 patients with paroxysmal (71%) or persistent (29%) AF who underwent index PVI using CB2 at our hospital between January 2013 and June 2017 were enrolled. Atrial tachyarrhythmia (ATa)-free survival was defined as the absence of AF, atrial flutter, or atrial tachycardia recurrence ≥30 s following a 3 months blanking period. Predictors of recurrence were evaluated by univariate and multivariate Cox proportional hazards regression models. Results:Acute procedural success rate was 99.8% (1898( /1902. Mean procedural and fluoroscopy time were 64.9 ± 9.2 and 12.1 ± 2.6, respectively. At median 39 (interquartile range: 26-56) months follow-up, ATa-free survival was 78.6% after a single procedure (280/345 [81.2%] for paroxysmal AF vs. 102/141 [72.3%] for persistent AF, P = .019) and 84.4% after a mean 1.48 ± 0.42 ablations. Cox regression analysis showed that left atrium diameter, duration of AF history, and early ATa recurrence were found as the independent predictors of late recurrence.Phrenic nerve palsy was observed in 17 (3.5%) patients. Conclusions:CB2-based PVI is effective to maintain sinus rhythm in a significant proportion of paroxysmal and persistent AF patients with an acceptable complication rate at long-term follow-up. K E Y W O R D S atrial fibrillation, complication, cryoballoon, recurrence 1 INTRODUCTION As pulmonary vein (PV) isolation (PVI) is accepted as the cornerstone of all atrial fibrillation (AF) ablation procedures, recent expert consen-sus document recommends to isolate PVs at first either using point-bypoint radiofrequency (RF) or cryoballoon (CB) ablation in all patients, including paroxysmal and nonparoxysmal AF. 1 CB technology has been shown to be as effective as RF technique for AF ablation. 2 910

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Section: Discussionsupporting

confidence: 93%

Section: Discussionmentioning

confidence: 99%

Long‐term outcomes of pulmonary vein isolation using second‐generation cryoballoon during atrial fibrillation ablation

Canpolat

Koçyiğit²,

Yalçın

et al. 2019

Pacing Clinical Electrophis

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“…Again, its value in PerAF is less well documented. Some early studies showed very low success rates in the range of 30-40%, whereas more recent trials reported efficacy exceeding 50% [2][3][4][5] . The rationale for using CB in PerAF is based on the fact that CB not only effectively isolates PV but also affects surrounding atrial tissue, and thus also modifies the substrate for AF [10] .…”

Section: Discussionmentioning

confidence: 99%

“…While the value of RF ablation in PerAF has been examined by several studies [1] the role of CB ablation in these patients is less clear. A few studies have suggested that this technique may be useful in PerAF, reaching an efficacy rate of 59-65% [2][3][4][5] . However, data are limited and come from highvolume and very experienced centres.…”

Section: Introductionmentioning

confidence: 99%

Cryoballoon ablation for persistent atrial fibrillation: real-life results from medium volume centre

Kułakowski¹,

Sikorska²,

Adach³

et al. 2019

Heart Beat

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Introduction. The value of cryoballoon (CB) ablation for paroxysmal atrial fibrillation (AF) has been well established. However, the safety and efficacy of CB ablation in persistent AF (PerAF) are less well known. The aim of the present study was to assess efficacy of CB in PerAF in comparison to RF ablation and to identify predictors of successful CB ablation in PerAF performed in a medium volume centre.Methods. Of 303 AF ablations, 92 (30%) procedures were performed in patients with PerAF: 38 CB (mean age 58±9 years, all first-time procedures) and 54 RF ablations, of which in 18 (33%) patients (mean age 57±12 years) this was the first-time procedure. The patients were prospectively followed (mean 14 ± 7 months) by repeated Holter ECG and outpatient visits.Results. After first-time procedures, recurrences of AF were noted in 15 (40%) patients from the CB group and in 15 (83%)

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“…In an observational study of 281 patients with persistent AF, long‐term outcomes after second generation cryoballoon evaluation were examined. The 1‐year freedom from the clinical atrial arrhythmia rate was 76%, which fell over 5 years to approximately 50% . Although these rates are similar to those achieved with radiofrequency ablation catheters because the second generation cryoballoon is a more durable tool for pulmonary vein isolation, the mechanisms behind these persistently elevated arrhythmia recurrence rates need to be better understood.…”

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confidence: 88%

Too much, too little, or just right?: Applying the Goldilocks principle to cryoballoon ablation for atrial fibrillation

Bunch

2018

Cardiovasc electrophysiol

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Disclosure: None.A popular 19th century fairy tale involves a young girl named Goldilocks, who ventures out into the woods. She comes across a small cottage, knocks on the door, and finding it empty, enters. On a table in the kitchen, she encounters three bowls of porridge. She tastes each and finds that the first is too hot, the second too cold, and the third just right. Throughout the tale, she encounters may things in threes, all of which test the principle of finding something that is of just the right amount. This concept has become known as the Goldilocks Principle.When considering cryothermal balloon ablation for the treatment of atrial fibrillation (AF), applying the Goldilocks principle and finding the right amount of energy to deliver has been a challenge.Cryothermal balloon ablation is not alone in this challenge; this impacts all forms of ablation currently used. However, cryothermal ablation is unique as it can homogenize operator experiences and approaches and uses discrete time periods of energy delivery. As a favorable consequence of a more simplistic technical approach, the use of this technology can be promoted to achieve similar outcomes across a broad scope of operators. As a negative consequence, without a true understanding of the principle of too much, too little, or what is just right, untoward complications will predictably rise when excessive injury is delivered. The first-generation cryoballoon had nonhomogeneous balloon cooling with freezing primarily along the equator. In an early experience, 35 of 71 patients that underwent cryoballoon ablation for AF had recurrences of AF or tachycardia. In those patients with recurrence, 26 underwent a repeat electrophysiology study. Of the 97 pulmonary veins that were identified as treated, 67 (69%) had recurrent conduction. 1 Recurrences typically were found in inferior segments of the vein and were felt to reflect improper alignment of the balloon and an equatorial zone of cooling. Cryoballoon modifications including optimizing the flow of refrigerant, increasing the number of refrigerant jets within the balloon from four to eight, and positioning the jets closer to the distal balloon were made for improving thermal energy transfer to the tissue and circumferential cooling of the balloon including the tip region. 2 The device modifications favorably impacted the pulmonary vein recurrence rate in a comparative study of 206 patients, of whom 18 underwent a repeat electrophysiology study. In those that had a repeat procedure, 77% of the veins initially isolated with the second generation balloon were still isolated compared with 32% of those treated with the first generation balloon. 3 In another small comparative study of 56 repeat ablation patients between second generation cryoballoon ablation and force-sensing radiofrequency ablation, pulmonary vein recurrences were less in the cryoballoon group (36% vs 20%). 4The Goldilocks principle is in essence a "U" shaped curve paradigm.As the pendulum swings from that of "too little" toward "just right,"...

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Five‐year experience with pulmonary vein isolation using the second‐generation cryoballoon for treatment of persistent atrial fibrillation

Abstract: PVI using CB-Adv in patients with persistent AF is accompanied by a learning curve and facilitates a satisfactory outcome, followed by the proper selection of patients.

Cited by 11 publications

References 23 publications

Long‐term outcomes of pulmonary vein isolation using second‐generation cryoballoon during atrial fibrillation ablation

Long‐term outcomes of pulmonary vein isolation using second‐generation cryoballoon during atrial fibrillation ablation

Cryoballoon ablation for persistent atrial fibrillation: real-life results from medium volume centre

Too much, too little, or just right?: Applying the Goldilocks principle to cryoballoon ablation for atrial fibrillation

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