Second-generation cryoballoon ablation without the use of real-time recordings: A novel strategy based on a temperature-guided approach to ablation

Iacopino, Saverio; Mugnai, Giacomo; Takarada, Ken; Paparella, Gaetano; Ströker, Erwin; Regibus, Valentina De; Coutiño-Moreno, Hugo Enrique; Choudhury, Rajin; Abugattas, Juan-Pablo; Brugada, Pedro; Asmundis, Carlo de; Chierchia, Gian‐Battista

doi:10.1016/j.hrthm.2016.11.023

Cited by 40 publications

(31 citation statements)

References 20 publications

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“…As confirmed by our results, late isolation (eg, later than 60 seconds) in the context of single freeze is associated with a significant rate of late PVr (50% vs 22.6%; P < .001) in line with previous observations . Technological innovation in recording catheters lead to higher rates of RT; however, encouraging success rates were reported even in CbA performed without a recording catheter . Despite the relatively low rate of RT in our population of redo procedures, we confirmed, overall, a comparable behavior of predictors in both groups of PVs (with and without available RT recordings).…”

Section: Discussionsupporting

confidence: 91%

Predictors of durable electrical isolation in the setting of second‐generation cryoballoon ablation: A comparison between left superior, left inferior, right superior, and right inferior pulmonary veins

Scala

Borio

Paparella

et al. 2019

Cardiovasc electrophysiol

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Aim The aim of this study is to assess specific per‐vein procedural predictors of pulmonary vein (PV) late reconnection in cryoballoon ablation (CbA) Methods and Results We enrolled 148 consecutive patients undergoing a redo procedure after a previous index CbA in our center. A reconnection in at least one PV was found in 80 patients (54.1%) and the most frequently reconnected PV was the right inferior pulmonary vein (RIPV). Overall, pulmonary vein reconnection (PVr) was associated with longer time to −40°C (Tt−40°C) (54.4 ± 21.7 vs 67.6 ± 27.6 seconds; P < .001), warmer nadir temperature (NT) (−49.7°C ± 5.4°C vs −46.5°C ± 5.8°C; P < .001) and temperature at 60 seconds (−41.8°C ± 4.5°C vs −39.8°C ± 4.2°C; P < .001). The performance of these predictors differed between the veins. In particular, a comparable behavior was observed for left superior pulmonary vein (LSPV) and right superior pulmonary vein (RSPV), where NT ≤ −48°C showed a sensibility and a specificity, respectively, of 62% and 65% and 71% and 72% in predicting durable PV isolation. For RIPV, NT ≤ −48°C showed a sensitivity of 74% but low specificity (53%). Tt −40°C less than 60 seconds showed good negative predictive values, respectively, 83.9% for LSPV, 94.9% for left inferior pulmonary vein (LIPV), 90.2% for RSPV, and 82.7% for RIPV. Previous predictors cannot be used for LIPV. Conclusions Freezing behavior and reconnection rates differ significantly among the four PVs. Freezing temperature parameters strongly predict late PVr in superior PVs and are slightly different in RIPV but can be applied as well. LIPV freezing behavior is the most different. Its reconnection is uncommon even in the subset of worse freezing temperatures and specific CB predictors cannot be identified.

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Section: Discussionsupporting

confidence: 91%

Predictors of durable electrical isolation in the setting of second‐generation cryoballoon ablation: A comparison between left superior, left inferior, right superior, and right inferior pulmonary veins

Scala

Borio

Paparella

et al. 2019

Cardiovasc electrophysiol

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“…Cryosurgical animal studies have demonstrated that maximal tissue damage occurs when a temperature below -40℃ is obtained with a rapid temperature drop (>10℃/min) 14 . Recent articles have reported that achieving -40℃ in 60 seconds is an independent predictor of durable PVI 15,16 .…”

Section: Discussionmentioning

confidence: 99%

A novel individualized strategy for cryoballoon catheter ablation in patients with paroxysmal atrial fibrillation

Ding

Wei

et al. 2019

Preprint

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Background : The optimal dosage for cryoablation of atrial fibrillation (Cryo-AF) is still unknown. To evaluate the efficacy of an individualized freeze duration, we compared the clinical outcome of patients treated with a time-to-pulmonary vein isolation (TT-PVI) or temperature-guided ablation protocol to the outcome of patients treated with a conventional ablation protocol. Methods: A total of 164 consecutive patients were included in the study. One method employed was a conventional dosing protocol (at least 2 applications of 180 seconds each)(the Cryo-AF Conventional group n=84), and the second method had a shorter protocol that was based on the TT-PVI or achievement of -40°C within 60 seconds (the Cryo-AF Dosing group n=80). Results: We treated 656 pulmonary veins (PVs) with 1420 cryotherapy applications. The mean number of applications per patient was 8.7±0.8, with no difference between groups (Cryo-AF Conventional , 8.7±0.8 versus Cryo-AF Dosing ,8.6±0.8; P =0.359). The Cryo-AF Dosing group required significantly less total cryotherapy application time (990.60±137.77versus 1501.58±89.60 seconds; P <0.001) and left atrial dwell time (69.91±6.91 versus 86.48±7.03 minutes; P <0.001) than the Cryo-AF Conventional group. Additionally, the Cryo-AF Dosing group required significantly less total procedure time (95.03±6.50 versus 112.43±7.11 minutes; P <0.001). We observed acute ATP-induced or spontaneous vein electric reconnections in 13 veins (1.98%) after 20 minutes. The reconnection rates between the Cryo-AF Conventional and Cryo-AF Dosing groups were similar in that 2.98% and 0.94% of the initially isolated veins were reconnected, respectively, ( P =0.061). There was no difference in the recurrence rate of free atrial arrhythmia after a 1-year follow-up, which were 78.75% in the Cryo-AF Dosing group versus 78.57% in the Cryo-AF Conventional group ( P =0.978). Conclusion: A novel Cryo-AF dosing protocol guided by temperature or the TT-PVI can be used to individualize an ablation strategy. This new protocol can lead to a significant reduction in duration of the procedure, the cryoenergy dosage and the left atrial dwell time. The procedure had equal safety and similar acute and 1-year follow-up outcomes compared to the conventional approach.

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“…Based on the findings documented throughout this all period, a second freeze‐thaw cycle was then delivered if, during the first application, PV isolation occurred after 60 seconds or if the temperature of −40°C was not reached during within the first 60 seconds of the cryo‐application . If no PVPs were detected before and during ablation, from 2017, the temperature‐based approach of −40°C within first 60 seconds was taken as a reference to define an effective cryo‐application . Durable PV isolation was then assessed for each PV at the end of the procedure.…”

Section: Methodsmentioning

confidence: 99%

“…14 If no PVPs were detected before and during ablation, from 2017, the temperaturebased approach of −40°C within first 60 seconds was taken as a reference to define an effective cryo-application. 15 Durable PV isolation was then assessed for each PV at the end of the procedure. During the whole procedure, activated clotting time was maintained over 250 seconds by supplementing heparin infusion, as required.…”

Section: Cb-a Proceduresmentioning

confidence: 99%

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

Maj

Borio

Osório

et al. 2020

Journal of Arrhythmia

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Background The prevalence and the clinical impact of conversion of atrial fibrillation (AF) to sinus rhythm (SR) during cryoballoon ablation (CB‐A) are unknown. Objective The purpose of this study was to evaluate the prevalence of restoration of SR during CB‐A and the clinical impact of this phenomenon. Methods Between January 2012 and September 2018, all patients who experienced conversion of AF to SR during CB‐A were included. This group was subsequently matched for gender, age, type of AF, diagnosis‐to‐ablation time, and left atrial size with patients who underwent CB‐A and did not experienced conversion of AF to SR. After discharge, patients were scheduled for follow‐up visits at 1, 3, 6, and 12 months and 24 hours Holter recordings were obtained at each follow‐up visit. All documented AF episodes of >30 seconds were considered as recurrence. A 3 month post‐procedural blanking period (BP) was applied. Results A total of 1559 patients underwent pulmonary veins isolation by CB‐A between January 2012 and September 2018; among them, 58 patients (3.7%) experienced restoration of SR during CB‐A. In total, 53 patients (41 males [77.3%], mean age 61.4 ± 13.3 years) were included in the case group. During CB‐A, restoration of SR occurred more frequently during right‐side PVs applications (right inferior pulmonary vein 39.6%, right superior pulmonary vein 30.2%). If considering a BP, at 2 year follow‐up, freedom from recurrences was 86.5% in the case group and 68.0% in the control group (P = .036). Conclusion Conversion of AF to SR is a favorable and relatively frequent phenomenon during cryoballoon pulmonary vein isolation ablation.

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Second-generation cryoballoon ablation without the use of real-time recordings: A novel strategy based on a temperature-guided approach to ablation

Cited by 40 publications

References 20 publications

Predictors of durable electrical isolation in the setting of second‐generation cryoballoon ablation: A comparison between left superior, left inferior, right superior, and right inferior pulmonary veins

Predictors of durable electrical isolation in the setting of second‐generation cryoballoon ablation: A comparison between left superior, left inferior, right superior, and right inferior pulmonary veins

A novel individualized strategy for cryoballoon catheter ablation in patients with paroxysmal atrial fibrillation

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

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