The clinical impact of the left atrial posterior wall lesion formation by the cryoballoon application for persistent atrial fibrillation: Feasibility and clinical implications

Abstract

Introduction: The left atrial (LA) posterior wall (LAPW) has been targeted to improve the clinical outcomes in patients with persistent atrial fibrillation (PersAF). This study aimed to investigate the feasibility, safety, and clinical implications of cryoballoon (CB) applications on the LAPW to accomplish electrical isolation (EI) of the LAPW with CB.Methods: A total of 100 patients (males, 84; mean age, 64 ± 10 years) with PersAF were enrolled. The first 50 patients underwent only pulmonary vein isolation (PVI) (PVI-only group) and the remaining 50 patients underwent PVI and EI of the LAPW with CB (EI-LAPW group). Results:One-year sinus rhythm maintenance probability was significantly higher in the EI-LAPW group than in PVI-only group (80.0% vs 55.1%, P = 0.01). The success rate of constructing an LA roof block line (LA-RB), bottom block line, and EI of the LAPW was 92%, 60%, and 58%, respectively. The nadir CB temperature (−45°C ± 4°C vs −39°C ± 5°C, P = 0.005) and anatomical angle of the left atrial roof (106°C ± 30°C vs 144°C ± 17°C, P < 0.001) significantly predicted the successful LA-RB construction.The left ventricular ejection fraction was significantly higher in unsuccessful cases than in successful cases of an EI of the LAPW (64% ± 8% vs 58% ± 11%, P = 0.041).Even though the EI of the LAPW was unsuccessful, CB freezing in LAPW significantly debulked the nonscar area (≥0.1 mV) in LAPW (18.1 ± 5.6 vs 2.2 ± 3.1 cm 2 , P < 0.001) and provided the equivalent 1-year outcome of successful cases (79.3% vs 81.0%, P = 0.90). Conclusion:The combination of PVI and EI of the LAPW with CB provided better clinical outcomes than conventional PVI procedure for patients with PersAF. K E Y W O R D S atrial fibrillation, cryoballoon, electrical isolation of left atrial posterior wall J Cardiovasc Electrophysiol. 2019;30:805-814.wileyonlinelibrary.com/journal/jce

Clinical investigation of the durability of the lesions created by left atrial linear ablation with a cryoballoon

“…Although the PVI is a standard established therapeutic strategy in AF ablation, the clinical outcome after an ablation procedure with only a PVI is still unsatisfactory, especially in non‐paroxysmal patients with AF. Recently, the second generation CB has been applied for linear ablation on the LAPW with a high success rate and without any serious complications including esophageal injury 6–9,13 . In this cohort, we were able to draw the clinical implications of the linear ablation on the LAPW with the CB from the result of a low arrhythmia recurrence rate (24.1%).…”

“…The ablation procedure has been previously described in detail 8 . In brief, a single transseptal puncture was performed under fluoroscopic and intracardiac echocardiographic (Acuson, AcuNav; Biosense Webster, Diamond Bar, CA) guidance.…”

“…The ablation procedure has been previously described in detail. 8 In brief, a single transseptal puncture was performed under fluoroscopic and intracardiac echocardiographic (Acuson, AcuNav; Biosense Webster, Diamond Bar, CA) guidance. The CB catheter (Arctic Front Advance; Medtronic, Minneapolis) was introduced into the LA through a steerable sheath (Flexcath Advance; Medtronic).…”

“…Linear ablation in the left atrium (LA) including of the roof and bottom line of the LA posterior wall (LAPW) that connect the ostia of both‐sided superior PVs and inferior PVs, and the resultant LAPW isolation, is one of the additional therapeutic methods after the PVI 5 . There have been several reports in which an LAPW roof line creation and LAPW isolation could be successfully completed by the CB 6–9 . However, there have been few investigations regarding the long‐term durability of the lesions on the LAPW roof and bottom line created by the CB application.…”

“…5 There have been several reports in which an LAPW roof line creation and LAPW isolation could be successfully completed by the CB. [6][7][8][9] However, there have been few investigations regarding the longterm durability of the lesions on the LAPW roof and bottom line created by the CB application. The aim of the present study was to investigate the long-term durability of the linear lesions in the LA with the CB and to find reliable predictors of the durability of these lesions.…”