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BACKGROUND: Pulmonary vein isolation (PVI) alone for persistent atrial fibrillation (PersAF) remains controversial. The characteristics of cryoballoon ablation (CBA) to treat PersAF and the blanking period recurrence are underreported. METHODS: This study retrospectively analyzed patients with PersAF undergoing second-generation CBA for de novo PVI. The post-procedural efficacy and survival analysis were compared between patients with different PersAF durations. The multivariate Cox regression analysis was used to detect the risk factors for recurrence. Early and long-term recurrence were analyzed relative to each other. RESULTS: A total of 329 patients were enrolled, with a median PersAF duration of 4.0 months (interquartile range: 2.0-12.0 months); 257 patients (78.1%) were male. Kaplan-Meier analysis of freedom from atrial fibrillation recurrence at 12, 24, and 30 months showed 71.0%, 58.5%, and 54.9%, respectively. Early PersAF had a relatively favorable survival rate and a narrow P-wave duration of restoring sinus rhythm compared with that of PersAF lasting more than three months (P < 0.05). The multivariate Cox regression analysis revealed that PersAF duration and left atrial anteroposterior diameter ≥ 42 mm were the risk factors for atrial fibrillation recurrence after CBA [hazard ratio (HR) = 1.89, 95% CI: 1.01-1.4, P = 0.042; HR = 3.6, 95% CI: 2.4-5.4, P < 0.001, respectively]. The blanking period recurrence predicted the long-term recurrence (P < 0.0001). CONCLUSIONS: CBA of PersAF had safety and efficacy to reach de novo PVI. The PersAF duration and left atrial size were risk factors for atrial fibrillation recurrence after CBA. Blanking period recurrence was associated with long-term recurrence.
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Aims: The aim was to describe the incidence of atrial fibrillation (AF) after cavotricuspid isthmus (CTI) ablation in patients with typical atrial flutter (AFL) without history of AF and to identify risk factors for new-onset AF after the procedure. Methods: A total of 191 patients with typical AFL undergoing successful CTI ablation were enrolled. Patients who had history of AF, structural heart disease, cardiac surgery, or ablation or who received antiarrhythmic drug after procedure were excluded. Clinical and electrophysiological data were collected. Results: There were 47 patients (24.6%) developing new AF during a follow-up of 3.3 ± 1.9 years after CTI ablation. Receiver operating characteristic (ROC) curves indicated that the cut-off values of left atrial diameter (LAD) and CHA2DS2-VASc score were 42 mm and 2, with area under the curve of 0.781 and 0.550, respectively. The multivariable Cox regression analysis revealed that obstructive sleep apnea (OSA) [hazard ratio (HR) 3.734, 95% confidence interval (CI) 1.470-9.484, P = 0.006], advanced interatrial block (aIAB) (HR 2.034, 95% CI 1.017-4.067, P = 0.045), LAD > 42 mm (HR 2.710, 95% CI 1.478-4.969, P = 0.001), and CHA2DS2-VASc score > 2 (HR 2.123, 95% CI 1.118-4.034, P = 0.021) were independent risk factors of new-onset AF. Conclusion: A combination of OSA, aIAB, LAD > 42 mm, and CHA2DS2-VASc > 2 was a strongly high risk for new-onset AF after ablation for typical AFL, and it had significance in postablation management in clinical practice.
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Background: Common ostium of inferior pulmonary veins (COIPV) is a kind of pulmonary vein variation. The safety and efficacy of COIPV isolation using the second-generation cryoballoon (CB) ablation remain unknown. Methods: A total of 10 patients with COIPV from a consecutive series of 1,751 patients with atrial fibrillation (AF) were included. Pulmonary vein isolation (PVI) was performed using the second-generation CB. Results: The prevalence of a COIPV was 0.57% in this study. PVI was achieved in all pulmonary veins (PVs) without the need for a touch-up. A segmental freeze strategy was applied for each inferior PV, respectively. The mean number of freeze cycles of inferior PVs was 1.4 ± 0.5 for the left inferior pulmonary vein (LIPV), and 2.0 ± 0.9 for the right inferior pulmonary vein (RIPV). Pulmonary vein potential (PVP) of RIPV could not be monitored in real-time in three cases. Eight of 10 patients (80%) were free from atrial arrhythmias without the use of antiarrhythmic drugs during a follow-up period of 23.6 ± 12.9 months. No procedure-related complications occurred in any of the 10 patients. Conclusions: Common ostium of inferior pulmonary veins is a rare but challenging PV variant. PVI with this unusual anatomic variation using the second-generation 28-mm CB is effective and safe.
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Background: Several methods have been reported for locating the conduction gap (CG) in the pulmonary vein isolation (PVI) ablation line. However, the value of the interval between far-field atrial potential (FFP) and pulmonary vein potential (PVP) remains unknown. Methods: Consecutive patients with a CG during observation on the table after PVI were included. The PVP, FFP, and the CG location were evaluated to develop a novel algorithm to identify the CG location in the left superior pulmonary vein. The performance of this novel algorithm was prospectively tested in a validation cohort of consecutive patients undergoing repeat PVI ablation. Results: A total of 116 patients with atrial fibrillation (AF) were recruited, 56 of whom formed the validation cohort. The interval between FFP and PVP of the left superior pulmonary vein was associated with the CG location, and an interval <5 ms predicted the presence of CG in the upper portion of the ostium with a sensitivity of 92.9% and a specificity of 96.9%. In the prospective evaluation, the interval was able to correctly predict the site of CG in 89.6% of cases. Conclusions: The interval between FFP and PVP is a novel and accurate index that can be used to predict the CG location in the left superior pulmonary vein. An far-field atrial potential and pulmonary vein potential (FFP-PVP) interval value of ≥5 ms could be used to exclude a CG in the upper portion of the ostium in the majority of patients undergoing AF ablation.
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Aims: To compare the procedural outcomes of cryoballoon ablation (CBA) and radiofrequency ablation (RFA) in atrial fibrillation (AF) patients with the common ostium of inferior pulmonary veins (COIPV) and to explore the effect of COIPV on CBA performance through the assessment of anatomical factors. Methods: A total of 18 AF patients with COIPV were included. Pulmonary vein isolation (PVI) was performed with second-generation CBA or RFA. The anatomical characteristics of COIPV and procedural outcomes were collected. Results: The prevalence of COIPV was 0.82% in the enrolled population. PVI was achieved in all pulmonary veins (PVs) without any complications. The "tricircle" strategy was applied for RFA, and the segmental freeze strategy was performed for CBA. Compared with RFA, CBA had shorter procedural time (median: 53.0 vs. 78.0 min, p < 0.001) and longer fluoroscopy time (median: 13.5 vs. 6.0 min, p < 0.001). Higher ovality index of the ostium was seen in patients with ≥4 freezes in inferior PVs [IPVs; 0.95 (0.78-1.05) vs. 0.49 (0.21-0.83), p = 0.047]. During a median of 23.5 months of follow-up, the atrial arrhythmias-free survival after the procedure was comparable between CBA and RFA (p = 0.729). Conclusion: The second-generation CBA is an efficient and safe alternative for RFA in AF patients with COIPV. Anatomical characteristics of COIPV bring the challenge to the procedure performance of RFA and CBA.
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BACKGROUND: Atrial fibrillation (AF) is a generally acknowledged turning-point of the natural history of hypertrophic cardiomyopathy (HCM); however, data from the cryoballoon ablation (CBA) for AF in HCM patients are relatively scarce. The study aimed to evaluate the efficacy and safety of CBA in HCM patients with AF. METHODS: We retrospectively analyzed HCM patients among 1253 patients with symptomatic AF who underwent CBA for pulmonary vein isolation in a single center. The study analyzed the AF recurrence and assessed the CBA indexes, including nadir temperature, time-to-isolation, CBA failure, pulmonary vein potentials (PVPs), and redo procedure. RESULTS: A total of 108 patients were included (mean age: 59.0 ± 6.9 years), 27 patients (25%) had HCM, with the median follow-up duration of 25.5 months. The one-year AF-free rates were 79.0% vs. 63.0% (non-HCM vs. HCM), while the two-year AF-free rates were 77.8% vs. 55.1% [hazard ratio (HR) = 2.758, log-rank P = 0.024]. Patients with persistent AF had poor AF-free rates compared to those with paroxysmal AF (P < 0.001). The CBA failure was the most common in the right inferior pulmonary veins, which had the lowest PVPs. Multivariate Cox regression analysis indicated that HCM and persistent AF were risk factors for AF recurrence (HR = 2.74, 95% CI: 1.29-5.79, P = 0.008; and HR = 3.97, 95% CI: 1.85-8.54, P < 0.001, respectively). CONCLUSIONS: The CBA can be effectively and safely used to treat HCM patients with symptomatic AF. The freedom from AF for HCM patients after CBA is relatively low compared to that for non-HCM patients.
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BACKGROUND: The safety and efficacy of superior vena cava (SVC) isolation using second-generation cryoballoon (CB) ablation remain unknown. METHODS: A total of 26 (3.2%) patients with SVC-related paroxysmal atrial fibrillation (AF) from a consecutive series of 806 patients who underwent second-generation CB were included. Pulmonary vein isolation was initially achieved by CB ablation. If the SVC trigger was determined, the electrical isolation of SVC isolation was performed using the second-generation CB. RESULTS: Real-time SVC potential was observed in all patients. Isolation of the SVC was successfully accomplished in 21 (80.8%) patients. The mean number of freeze cycles in each patient was 2.1 ± 1.1. The mean time to isolation and ablation duration were 22.5 ± 14.2 seconds and 94.5 ± 22.3 seconds, respectively. A transient phrenic nerve (PN) injury was observed in five patients (19.2%). There were two patients (7.7%) experienced reversible sinus node injury during the first application. During a mean follow-up period of 13.2 ± 5.8 months, four patients (15.4%) had atrial arrhythmia recurrences. CONCLUSION: Isolation of SVC using the second-generation 28-mm CB is feasible when SVC driver during AF is identified. Vigilant monitoring of PN function during CB ablation of SVC is needed to avoid PN injury.
