Long-term outcomes of left atrial appendage isolation using cryoballoon in persistent atrial fibrillation

Abstract

Aims There is an increasing trend evaluating the role of non-pulmonary vein (PV) triggers to improve ablation outcomes in persistent atrial fibrillation (AF) as pulmonary vein isolation (PVI) strategy alone has modest outcomes. We investigated the long-term safety and efficacy of left atrial appendage isolation (LAAi) in addition to PVI using cryoballoon (CB) in persistent AF. Methods and results In this multicentre retrospective analysis, we included a total of 193 persistent AF patients (mean age: 60 ± 11 years, 50.3% females) who underwent PVI and LAAi using CB. Baseline and follow-up data including electrocardiography (ECG), 24 h Holter ECGs, and echocardiography were recorded for all patients. Atrial tachyarrhythmia (ATa) recurrence was defined as the detection of AF, atrial flutter, or atrial tachycardia (≥30 s) after a 3-month blanking period. At a median follow-up of 55 (36.5–60.0) months, 85 (67.9%) patients with PVI + LAAi were in sinus rhythm after the index procedure. Ischaemic stroke/transient ischemic attack occurred in 14 (7.2%) patients at a median of 24 (2–53) months following catheter ablation. Multivariate regression analysis revealed heart failure with preserved ejection fraction [hazard ratio (HR) 2.29, 95% confidence interval (CI) 1.04–5.02; P = 0.038], male gender (HR 0.53, 95% CI 0.29–0.96; P = 0.037), and LA area (HR 1.04, 95% CI 0.53–1.32; P = 0.023) as independent predictors of ATa recurrence. Conclusion Our findings demonstrated that the LAAi + PVI strategy using CB had acceptable long-term outcomes in patients with persistent AF. Systemic thrombo-embolic events are an important concern throughout the follow-up, which were mostly observed in case of non-adherence to anticoagulants.

Cryoballoon ablation of non‐PV triggers in persistent atrial fibrillation

“…In the long-term follow-up results of our study with a median follow-up period of 55 (36.5−60.0) months, 14 patients experienced thromboembolic events. 72 Notably, all these thromboembolic events were linked to the interruption of oral anticoagulation therapy, and the majority occurred after 12 months following LAAi. In four patients, thrombus was found in the LAA during routine evaluation with transesophageal echocardiography (TEE), all of which were resolved using optimal oral anticoagulation therapy.…”

“…Different from the abovementioned studies, we noted a relatively lower incidence of ischemic stroke and LAA thrombus in our study. 72 This discrepancy might be attributed to several factors. Firstly, the majority of our patients who underwent LAAi were in the early stages of PeAF with a median AF duration of 24 months (6.5−50).…”

“…patients, and all of them were resolved with intracoronary nitrate infusion. 72 In another clinical trial, Romero et al 84 highlighted the anatomical relationship between the left main coronary artery, lateral Cx, and anterior edge of LAA using cardiac computed tomography in patients undergoing LAAi. Therefore, considering this anatomical rela-tionship is important to recognize and intervene for early coronary artery trauma during ablation.…”

“…81,85 In our studies, successful LAAi using a CB was achieved in 90.6%, 91.1%, and 94.4% of patients, respectively. [70][71][72] Despite high acute isolation rates, durability of LAAi is still an important concern. Tohoku et al 81 reported that durable LAAi was present at 6 weeks in 66% of patients who underwent LAAi using a CB.…”

Ganglionic Plexus Ablation: A Step-by-step Guide for Electrophysiologists and Review of Modalities for Neuromodulation for the Management of Atrial Fibrillation

“…[7][8][9] While traditional focus has been on pulmonary vein isolation (PVI), more recent advanced approaches, including isolation of the posterior wall of the left atrium, ablation of the vein of Marshall (VoM), superior vena cava isolation, left atrial appendage isolation, rotor mapping and ablation, non-PV trigger ablation, scar homogenisation and other strategies, have been explored to limit recurrence in those with persistent forms of AF but with only incremental additional effectiveness compared with PVI alone in clinical studies. [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] More recently, novel energy sources and mapping algorithms have also been explored for AF catheter ablation. [27][28][29][30][31][32][33] Even with more sophisticated approaches, superior longterm effective treatment for AF above what is achievable with PVI alone has been a challenge.…”