P2849Prevalence and significance of sustained pulmonary vein isolation in repeat AF ablation procedures

Abstract Introduction Pulmonary vein (PV) reconnection is a common cause of relapse after catheter ablation of atrial fibrillation (AF). However, some patients have AF recurrence despite durable PV isolation. The aim of this study was to assess the PV isolation status at the time of a second catheter ablation (redo) procedure, and its relationship with subsequent AF relapse. Methods Consecutive patients with symptomatic drug-resistant AF who underwent redo procedures from January 2006 to December 2017 were identified in a single-center observational registry. Pulmonary vein isolation status was assessed during the electrophysiologic study with a circular mapping catheter. Additional radiofrequency (RF) energy applications were also recorded. AF relapse was defined as symptomatic or documented AF/atrial tachycardia/atrial flutter after a 3-month blanking period. Results We identified 240 patients (77 [32%] females, median age 61 [IQR 53–67] years, 85 [35%] with non-paroxysmal AF) undergoing redo procedures during the study period. At the time of redo, 17 (7%) of the patients presented bidirectional conduction block of all PVs. PV reconnection occurred in 157 (65%) of cases in the left superior vein, 142 (59%) in the left inferior vein, 177 (73%) in the right superior vein, and 163 (68%) in the right inferior vein (table). All of the PVs were reconducted in 91 (38%) patients. Additional RF applications were performed in the left atrium (LA) roof, LA posterior wall, cavotricuspid isthmus, mitral isthmus, superior vena cava, coronary sinus, and left atrial appendage ostium, at the operator's discretion (table 1). Over a median follow-up of 2-years (IQR 1–5), 126 patients (53%) suffered AF recurrence, yielding a mean relapse rate of 17%/year. In multivariate Cox regression analysis, the lack of PV reconnection at the time of redo emerged as an independent predictor of subsequent relapse (HR 1.97, 95% CI 1.12–3.49, p=0.019) even after adjustment for univariate predictors including non-paroxysmal AF, body mass index, female sex, and active smoking. Conclusion In patients undergoing redo AF ablation procedures, less than 10% present with complete PV isolation. Despite being relatively infrequent, this finding is independently associated with greater likelihood of subsequent recurrence, suggesting that other mechanisms, not fully addressed by additional RF applications, are at play.

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Catheter ablation of atrial fibrillation without pulmonary vein isolation

EP Europace ◽

10.1093/europace/euab116.258 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

P Futyma ◽

L Zarebski ◽

A Wrzos ◽

M Futyma ◽

P Kulakowski

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Superior Vena ◽

Vena Cava ◽

Funding Sources ◽

The Right ◽

Ganglionated Plexus

Abstract Funding Acknowledgements Type of funding sources: None. Background Pulmonary vein isolation (PVI) is a cornerstone for catheter ablation (CA) of atrial fibrillation (AF), however, long-term efficacy of PVI is frequently below expectations. PVI is invasive, expensive and may be associated with devastating complications. It has been postulated that vagally-mediated AF can be treated by attenuation of parasympathetic drive to the heart using cardioneuroablation by means of radiofrequency CA (RFCA) of the right anterior ganglionated plexus (RAGP), however, data in literature and guidelines are lacking. Purpose To examine the efficacy of RFCA targeting RAGP without PVI in management of vagal AF. Methods We included consecutive 9 male patients with vagal AF who underwent RFCA of RAGP without PVI. RAGP was targeted anatomically from the right atrium (RA) at the postero-septal area below superior vena cava (SVC) and from the left atrium (LA) if needed. The aim was to achieve >30% increase in heart rate (HR) . The follow up consisted of regular visits and Holter ECG conducted every 3 months. Results A total number of 9 patients (age 52 ± 13) with vagally-mediated AF underwent RFCA of RAGP (mean RAGP RF time 147 ± 85, max power 34 ± 8W). The mean procedure time was 60 ± 29min. HR increase >30% was achieved in 8 (89%) patients (pre-RF vs post-RF: 58 ± 8bpm vs 87 ± 12bpm, p = 0.00002) . Transseptal to reach RAGP also from the LA was needed in 2 (22%) patients. There were no major complications during the procedures. The follow up lasted 6 ± 2 months. Antiarrhythmic drugs were discontinued in 8 (89%) patients. There was 1 (11%) AF recurrence in the patient in whom targeted HR acceleration during RFCA was not achieved. B-blockers were administered in 6 (67%) patients due to increased HR and such treatment was well tolerated by all. Conclusions Catheter ablation of RAGP without performing PVI is feasible and can be effective in majority of patients with vagally-mediated AF. Increased HR after such cardioneuroablation can be well controlled using b-blockers and is usually associated with mild symptoms. The role of cardioneuroablation for treatment of vagally-mediated AF needs to be determined in prospective trials. Abstract Figure. Cardioneuroablation in vagal AF

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P1059Recurrence of AF after pulmonary vein isolation: how many times?

EP Europace ◽

10.1093/europace/euaa162.316 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

P Silverio Antonio ◽

N Cortez-Dias ◽

A Nunes-Ferreira ◽

G Lima ◽

I Aguiar-Ricardo ◽

...

Keyword(s):

Prospective Study ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Pulmonary Veins ◽

High Rate ◽

Isolation Rate ◽

Af Ablation ◽

Mitral Isthmus ◽

The Right ◽

Af Recurrence

Abstract Introduction Ablation of atrial fibrillation (AF) by catheter is an effective therapy, particularly in cases of refractoriness to medical therapy. Pulmonary vein isolation (PVI) has a significative long-term recurrence rate of AF, but the recurrence factors after this procedure are poorly defined. Purpose To characterize the causes of AF recurrence after PVI and to evaluate complementary strategies that can optimize the therapeutic efficacy. Methods A single centre prospective study of patients (pts) with AF submitted consecutively to PVI since September 2004. The variables responsible for the recurrence of AF, the complementary strategies of optimization of AF ablation and the occurrence of other dysrhythmias were evaluated. Results A population of 521 pts were submitted to PVI as a primary strategy for AF treatment - 36.1% for paroxysmal AF, 32.5% for persistent AF <1 year, 14.5% persistent AF> 1 year. Eighty-three pts needed to perform 2 ablations and 10 pts performed 3 ablations. The higher the number of AF ablations, the higher the incidence of atypical atrial flutter (2% in the 1st AF ablation, 17% in the 2nd and 44% after 3 ablations). In the pts with recurrence of AF undergoing the 2nd ablation, it was verified that most of the pulmonary veins (PV) were not isolated, with an isolation rate of only 34.1% for the right inferior PV; 29.4% for superior PV right, 29.4% lower left VP, 28.2% upper left PV. In this group, in addition to a new PVI in the pts with re-conduction of PV, 45% performed complementary ablation strategies such as: ablation of the cavo-tricuspid isthmus (52.6%); ablation of the left atrium roof line (29%); mitral isthmus ablation line (26%); applications in the scar zone (26%); posterior atrial left line (8%), atrioventricular nodal reentrant atrioventricular ablation (5%), atrial tachycardia ablation (2.6%). In the pts submitted to the 3rd ablation, again a low PV isolation rate was confirmed: only 44.4% for the both left PV and upper right PV, and 55.6% for the right lower VP. 33.3% also performed cavo-tricuspid isthmus ablation, 22.2% lower mitral isthmus isolation and 22.2% re-isolation of gaps in the roof or intracicritricial line. Conclusion This prospective study demonstrates a high rate of PV re-conduction after PVI and its role in AF recurrence. Therefore, the need for a more effective and definitive IVP technique is evident.

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Anatomic variants of pulmonary venous drainage and their relation to recurrences of atrial fibrillation after pulmonary vein isolation

Bulgarian Cardiology ◽

10.3897/bgcardio.27.e71311 ◽

2021 ◽

Vol 27 (3) ◽

pp. 55-68

Author(s):

Svetla Dineva ◽

Milko Stoyanov ◽

Aneliya Partenova ◽

Boyan Kunev ◽

Victoria Stoyanova ◽

...

Keyword(s):

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Local Population ◽

Venous Drainage ◽

Anatomical Variant ◽

Cox Regression Analysis ◽

Anatomical Variants ◽

The Impact ◽

Variant Anatomy ◽

Af Recurrence

Anatomical variants of pulmonary venous drainage in the left atrium are often found. Divergent results have been reported on the impact of variant anatomy on atrial ﬁ brillation (AF) recurrence after catheter ablation. We aimed to study the frequency of different anatomical variants of pulmonary venous drainage and their relationship with documented recurrences of AF after ablation. Material and methods: A retrospective study of patients with AF in whom radiofrequency pulmonary vein isolation was done after previously performed cardiac contrast-enhanced multidetector computed tomography. Clinical and procedural characteristics, type and frequency of anatomical variants of the veno-atrial junction and their association with AF recurrences were studied. Results: One hundred seventy-seven patients (112 men, 63.3%) with AF were studied, of which 148 (83.6%) with paroxysmal AF. Variant anatomy was found in 91 patients (51.4%). In 20.9% there was a common left trunk, in 23.2% – more or less than two right-sided veins, and in 7.3% – variations for both right and left veins. No differences in clinical and procedural characteristics were found between the groups with normal and variant anatomy. Recurrences of AF and their association with pulmonary venous anatomy were studied in 104 patients with follow-up ≥ 3 months. No signiﬁ cant relation was found between the presence of variant anatomy and AF recurrences within the blinding period after ablation, OR = 0.864, 95% CI = 0.397 – 1.88, p = 0.843, nor afterwards, OR = 1.12, 95% CI = 0.5 – 2.5, p = 0.839. Cox regression analysis showed no differences in AF recurrence-free survival regardless of the anatomical variant of pulmonary venous drainage, HR = 1.09, 95% CI = 0.58 – 2.05, p = 0.779. Conclusion: In this local population of patients with AF, the incidence of variant pulmonary venous drainage is just over 50%. No association was found between variant anatomy and the rate of AF recurrences after ﬁ rst pulmonary vein isolation.

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Abstract 15934: Comparison of Atrial Fibrillation Burden Reduction in Patients With Paroxysmal and Persistent Atrial Fibrillation Undergoing Cryoballoon Pulmonary Vein Isolation

Circulation ◽

10.1161/circ.142.suppl_3.15934 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Dan L Musat ◽

Nicolle S Milstein ◽

Jacqueline Pimienta ◽

Advay Bhatt ◽

Tina C Sichrovsky ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Persistent Atrial Fibrillation ◽

Loop Recorder ◽

Similar Reduction ◽

Af Ablation ◽

Ablation Success ◽

One Year ◽

Af Recurrence

Background: Pulmonary vein isolation (PVI) is a cornerstone of atrial fibrillation (AF) ablation procedures to treat symptomatic AF. Ablation success is defined by absence of AF recurrence >30 seconds. However, reduction in AF burden (AFB) is also an important endpoint. Whether patients with paroxysmal (PAF) and persistent AF (PeAF) have similar reduction in AFB post-ablation is unknown. Objective: To compare the decrease in AFB following cryoballoon (CB) PVI in patients with PAF and PeAF. Methods: We enrolled consecutive pts with an implantable loop recorder (ILR) who subsequently underwent CB PVI. All patients were followed prospectively for at least one year, or until repeat ablation; we compared AFB pre and post-ablation. Results: The cohort included had 47 patients (66 ± 10 years; 32 [68%] male; PAF [n=23, 49%]; CHA 2 DS 2 -VASc 2.7 ± 1.7, 34 [72%] on AAD at the time of ablation). A median of 136 days [IQR 280, 73; minimum of 30 days] of ILR data pre-ablation were available. The median AFB for PAF was 4.7% [IQR 0.9, 14.8] and PeAF was 6.8% [IQR 1.1, 40.4]. After excluding a 3-month post-ablation blanking period, recurrent AF occurred in 12 (52%) PAF and 11 (46%) PeAF patients. The median AFB post-ablation for PAF and PeAF cohorts was 0.03%, [IQR 0, 0.3] and 0.04%, [IQR 0, 1.1], respectively. This represents a >99% reduction in AFB. Conclusion: Although 50% of patients undergoing CB PVI for PAF or PeAF had a recurrence of AF, there was >99% reduction in AFB in both groups. These data highlight the importance of using AFB burden as a marker of therapeutic efficacy post-AF ablation.

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Intraprocedural endpoints to predict durable pulmonary vein isolation: a randomized trial of four post-ablation techniques

EP Europace ◽

10.1093/europace/euz301 ◽

2019 ◽

Vol 22 (4) ◽

pp. 567-575 ◽

Cited By ~ 4

Author(s):

Ruhong Jiang ◽

Minglong Chen ◽

Bing Yang ◽

Qiang Liu ◽

Zuwen Zhang ◽

...

Keyword(s):

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Af Ablation ◽

Group 4 ◽

Initial Procedure ◽

Group 2 ◽

Waiting Periods ◽

The Impact ◽

Af Recurrence

Abstract Aims The optimal procedural endpoint to achieve permanent pulmonary vein isolation (PVI) during ablation of atrial fibrillation (AF) remains unknown. We aimed to compare the impact of prolonged waiting periods and adenosine triphosphate (ATP) testing after PVI on long-term freedom from AF. Methods and results In total, 538 patients (median age 61 years, 62% male) undergoing first-time radiofrequency ablation for paroxysmal AF were randomized into four groups: Group 1 [PVI (no testing), n = 121], Group 2 (PVI + 30min waiting phase, n = 151), Group 3 (PVI+ATP, n = 131), and Group 4 (PVI + 30min+ATP, n = 135). The primary endpoint was freedom from AF. Repeat mapping to assess for late pulmonary vein (PV) reconnection was performed in patients who remained AF-free for >3 years (n = 46) and in those who had repeat ablation for AF recurrence (n = 82). During initial procedure, acute PV reconnection was observed in 33%, 26%, and 42% of patients in Groups 2, 3, and 4, respectively. At 36 months, no significant differences in freedom from AF recurrence were observed among all four groups (55%, 61%, 50%, and 62% for Groups 1, 2, 3, and 4, respectively; P = 0.258). Late PV reconnection was commonly observed, with a similar incidence between patients with and without AF recurrence (74% vs. 83%; P = 0.224). Conclusion Although PVI remains the cornerstone for AF ablation, intraprocedural techniques to assess for PV reconnection did not improve long-term success. Patients without AF recurrence after 3 years exhibited similarly high rates of PV reconnection as those that underwent repeat ablation for AF recurrence. The therapeutic mechanisms of AF ablation may not be solely predicated upon durable PVI.

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Impact of the ablation technique on release of the neuronal injury marker S100B during pulmonary vein isolation

EP Europace ◽

10.1093/europace/euaa159 ◽

2020 ◽

Vol 22 (10) ◽

pp. 1502-1508

Author(s):

Katharina Scherschel ◽

Katja Hedenus ◽

Christiane Jungen ◽

Paula Münkler ◽

Stephan Willems ◽

...

Keyword(s):

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Cox Regression ◽

Cox Regression Analysis ◽

Ablation Technique ◽

Molecular Pattern ◽

Before And After ◽

Study Population ◽

First Time

Abstract Aims S100B, a well-known damage-associated molecular pattern protein is released acutely by central and peripheral nerves and upon concomitant denervation in pulmonary vein isolation (PVI). We aimed to investigate whether the ablation technique used for PVI impacts S100B release in patients with paroxysmal atrial fibrillation (AF). Methods and results The study population consisted of 73 consecutive patients (age: 62.7 ± 10.9 years, 54.8% males) undergoing first-time PVI with either radiofrequency (RF; n = 30) or cryoballoon (CB; n = 43) for paroxysmal AF. S100B determined from venous plasma samples taken immediately before and after PVI increased from 33.5 ± 1.8 to 91.1 ± 5.3 pg/mL (P < 0.0001). S100B release in patients undergoing CB-PVI was 3.9 times higher compared to patients with RF-PVI (ΔS100B: 21.1 ± 2.7 vs. 83.1 ± 5.2 pg/mL, P < 0.0001). During a mean follow-up of 314 ± 186 days, AF recurrences were observed in 18/71 (25.4%) patients (RF-PVI: n = 9/28, CB-PVI: n = 9/43). Univariate Cox regression analysis indicated that an increase in S100B was associated with higher freedom from AF in follow-up (hazard ratio per 10 pg/mL release of S100B: 0.83; 95% confidence interval: 0.72–0.95; P = 0.007). Conclusion The ablation technique used for PVI has an impact on the release of S100B, a well-established biomarker for neural damage.

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Abstract 2161: Left Atrium Reverse Remodeling After Pulmonary Vein Isolation. Will It Be a Predictor for Non-recurrence of Atrial Fibrillation?

Circulation ◽

10.1161/circ.118.suppl_18.s_678-c ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

kiyotake Ishikawa ◽

Yukihiko Yoshida ◽

Sumio Morita ◽

Kenji Furusawa ◽

Noriyoshi Kanemura ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Left Atrium ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Reverse Remodeling ◽

Transverse Diameter ◽

Before And After ◽

History Of ◽

Af Recurrence

Background: Left atrium (LA) dilation plays an important role in development and persistence of atrial fibrillation (AF). Some cases show structural reverse remodeling of LA after catheter ablation of AF. The aim of this study was to assess the clinical significance of LA reverse remodeling. Method and Results: Echocardiographic data before and after ablation was obtained in 173 cases who underwent pulmonary vein isolation from January 2006 to April 2008 (74.0% men, 61.0±11 years old; paroxysmal AF 114, persistent AF 34, permanent AF 25). Mean atrial diameter before ablation was 39.0±6.1mm (paroxysmal 37.7±5.6mm, persistent 40.7±5.3mm, and permanent 43.0±6.8mm) and LA reverse remodeling was defined as 10% decrement of LA transverse diameter. Half of the cases were taking anti-arrhythmic drugs after ablation, and AF recurrence occurred in 16.8% (29/173) during mean follow up period of 8.5±6.3 months. Reverse remodeling of LA was seen in 34.1% (59/173) and AF recurrence rate in this group was 11.9% (7/59), whereas 19.3% (22/114) without reverse remodeling (P=0.29). However, limited in patients with LA diameter over 40mm (44.5%; 77/173), 3.2% (1/31) of AF recurrence was seen in those with reverse remodeling, while 21.7% (10/46) without reverse remodeling (P=0.04). LA reverse remodeling was observed significantly frequent in patients without history of hypertension(41.5% without hypertension vs 25.6% with hypertension, P=0.036). Conclusion: LA reverse remodeling after catheter ablation of AF in dilated LA patient is a simple and useful predictor for non-recurrence of AF. Hypertension could be a disturbance for LA reverse remodeling.

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Abstract 2755: Increased Efficacy of Catheter Ablation Of Atrial Fibrillation by Using Adenosine to Reveal Dormant Pulmonary Vein Conduction

Circulation ◽

10.1161/circ.118.suppl_18.s_772-a ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Laurent Macle ◽

Atul Verma ◽

Paul Novak ◽

Paul Khairy ◽

Mario Talajic ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Pulmonary Vein ◽

Pulmonary Veins ◽

Historical Control Group ◽

Historical Control ◽

Control Group ◽

Af Ablation ◽

Dormant Conduction ◽

Af Recurrence

Recurrences of atrial fibrillation (AF) after catheter ablation are frequently associated with recovery of conduction between the pulmonary veins (PV) and the atrium. The recovery of PV conduction could be explained by the presence of dormant conduction between the PV and the atrium. Adenosine can be used during AF ablation procedures to reveal transient re-conduction of the isolated pulmonary vein (dormant PV conduction). We prospectively evaluate the utility of iv adenosine to guide elimination of dormant PV conduction by additional radiofrequency (RF) applications during AF ablation procedures. Thirty-four consecutive patients (30 male; age 51+/−8 years) referred for catheter ablation of drug-refractory AF (Paroxysmal 31/Persistent 3) were studied. Electrical PV isolation (PVI) was performed using Irrigated-tip radiofrequency (RF) ablation and was guided by a circular mapping catheter. After PVI, the presence of dormant conduction in each vein was assessed by injection of 12 mg of adenosine. If dormant conduction was present, additional RF energy was delivered at sites of transient re-conduction. Abolition of the dormant conduction was then demonstrated by repeated injections of adenosine. The recurrence rate of arrhythmia after one procedure was evaluated. The results were compared to an historical control group comprising the previous 34 consecutive patients who underwent PVI without the use of adenosine. Electrical PVI was achieved in 100% of PV’s and all 34 patients underwent the adenosine evaluation. Dormant PV conduction was observed in 17/34 patients and could be eliminated in all by additional RF delivery. Procedural and fluoroscopy times were 163±30 and 49±13 minutes, respectively. After a mean follow-up of 8.0±3.1 months, 6/34 (18%) patients experienced AF recurrence with 28/34 (82%) remaining free of arrhythmia without the use of antiarrhythmic drugs. When compared to the 14/34 patients (41%) from the historical control group who had AF recurrence, a significant reduction was observed (P<0.01). The use of adenosine to guide elimination of dormant PV conduction increases the success rate of AF ablation procedures. This needs to be evaluated in a randomized multicenter trial.

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Orientation of the right superior pulmonary vein affects outcome after pulmonary vein isolation

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeab041 ◽

2021 ◽

Author(s):

Nándor Szegedi ◽

Milán Vecsey-Nagy ◽

Judit Simon ◽

Bálint Szilveszter ◽

Szilvia Herczeg ◽

...

Keyword(s):

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Anatomical Variations ◽

Effective Diameter ◽

Free Survival ◽

Female Sex ◽

The Right ◽

The Impact ◽

Af Recurrence

Abstract Aims Controversial results have been published regarding the influence of pulmonary vein (PV) anatomical variations on outcomes after pulmonary vein isolation (PVI). However, no data are available on the impact of PV orientation on the long-term success rates of point-by-point PVI. We sought to determine the impact of PV anatomy and orientation on atrial fibrillation (AF)-free survival in patients undergoing PVI using the radiofrequency point-by-point technique. Methods and results We retrospectively included 448 patients who underwent initial point-by-point radiofrequency ablation for AF at our department. Left atrial computed tomography angiography was performed before each procedure. PV anatomical variations, ostial parameters (area, effective diameter, and eccentricity), orientation, and their associations with 24-month AF-free survival were analysed. PV anatomical variations and ostial parameters were not predictive for AF-free survival (all P > 0.05). Univariate analysis showed that female sex (P = 0.025) was associated with higher rates of AF recurrence, ventral-caudal (P = 0.002), dorsal-cranial (P = 0.034), and dorsal-caudal (P = 0.042) orientation of the right superior PV (RSPV), on the other hand, showed an association with lower rates of AF recurrence, when compared with the reference ventral-cranial orientation. On multivariate analysis, both female sex [odds ratio (OR) 1.83, 95% CI 1.15–2.93, P = 0.011] and ventral-caudal RSPV orientation, compared with ventral-cranial orientation, proved to be independent predictors of 24-month AF recurrence (OR 0.37, 95% CI 0.19–0.71, P = 0.003). Conclusion Female sex and ventral-caudal RSPV orientation have an impact on long-term arrhythmia-free survival. Assessment of PV orientation may be a useful tool in predicting AF-free survival and may contribute to a more personalized management of AF.

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Radiofrequency vs. Cryoballoon Catheter Ablation for Paroxysmal Atrial Fibrillation: Durability of Pulmonary Vein Isolation and Effect on AF Burden: The RACE-AF Randomized Controlled Trial

Circulation Arrhythmia and Electrophysiology ◽

10.1161/circep.120.009573 ◽

2021 ◽

Author(s):

Samuel K. Sørensen ◽

Arne Johannessen ◽

René Worck ◽

Morten L. Hansen ◽

Jim Hansen

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Paroxysmal Atrial Fibrillation ◽

Controlled Trial ◽

Pulmonary Veins ◽

Primary Methods ◽

Second Procedure ◽

Af Recurrence

Background - Recurrent paroxysmal atrial fibrillation (PAF) after catheter ablation is presumably caused by failure to achieve durable pulmonary vein isolation (PVI). The primary methods of PVI are radiofrequency (RF) and cryoballoon (CRYO) catheter ablation, but these methods have not been directly compared with respect to PVI durability and the effect thereof on AF burden (% of time in AF). Methods - Accordingly, we performed a randomized trial including 98 patients (68% male, 61 [55-67] years) with PAF assigned 1:1 to PVI by contact-force sensing, irrigated RF catheter or second-generation CRYO catheter. Implantable cardiac monitors were inserted ≥1 month before PVI for assessment of AF burden and recurrence, and all patients, irrespective of AF recurrence, underwent a second procedure 4-6 months after PVI to determine PVI durability. Results - In the second procedure, 152/199 (76%) pulmonary veins (PVs) were found durably isolated after RF and 161/200 (81%) after CRYO (NS), corresponding to durable isolation of all veins in 47% of patients in both groups (NS). Median AF burden before PVI was 5.4% (interquartile range: 0.5-13.0%) vs. 4.0% (0.6-18.1%), RF vs. CRYO, and reduced to 0.0% (0.0-0.1%) and 0.0% (0.0-0.5%), respectively - a reduction of 99.9% (92.9-100.0%) and 99.3% (85.9-100.0%) (all NS). AF burden after PVI significantly correlated to the number of durably isolated PVs (p < 0.01), but 9/45 (20%) patients with durable isolation of all veins had recurrence of AF within 4-6 months after PVI (excluding a 3-month blanking period). Conclusions - PVI by RF and CRYO catheter ablation produce similar moderate to high PVI durability. Both treatments lead to marked reductions in AF burden, which is related to the number of durably isolated PVs. However, for one fifth of PAF patients, complete and durable PVI was not sufficient to prevent even short-term AF recurrence.

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