Feasibility and safety of left atrial posterior wall isolation with a new Cryoballoon technology in patients with persistent atrial fibrillation

Introduction: Left atrial posterior wall isolation (LAPWI) is often performed in addition to pulmonary vein isolation (PVI) to improve outcome in patients with persistent atrial fibrillation (AF). In this setting, LAPWI + PVI using cryoballoon ablation had comparable results with radiofrequency ablation (RFA). The aim of the study is to evaluate the feasibility and safety of a new cryoballoon ablation system in PVI + LAPWI isolation, comparing it with the historical platform. Methods: The study was a prospective, non-randomized, single center study. Forty consecutive patients, undergoing PVI + LAPWI with the novel POLARx™, were compared to 40 consecutive patients who underwent the same procedure with the established Arctic Front Advance PRO™. Results: Acute isolation was achieved in all PVs in both groups and LAPWI was achieved in 38 patients (95%) in the POLARx group and in 36 patients (90%) in Arctic Front group. Procedural outcomes were similar between the two groups, except for lower temperatures during cryoapplications in the POLARx group, for both PVI and LAPWI. The complication rate was low and similar between groups. Conclusion: LAPWI+PVI with the novel POLARx™ Cryoballoon is feasible and safe; the results are comparable with the Arctic Front Advance PRO™ system.

Five-box thoracoscopic maze based on the Gemini-S bipolar ablation device to treat atrial fibrillation

Thoracoscopic atrial fibrillation ablation seeks to replicate the electrophysiological effects of more invasive, open surgical procedures. The authors present a lesion concept that includes isolation of the pulmonary veins, the left atrial posterior wall, and the superior vena cava, respectively, lines to inhibit perimitral and periauricular flutter circuits, and left atrial appendage closure. All lesions are tested for bidirectional block.

Impact of Left Atrial Posterior Wall Isolation Technique on the Outcome of Ablation in Persistent Atrial Fibrillation

Background Left atrial posterior wall (LAPW) isolation is an adjunct to pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF). Objective To compare the effect of LAPW box isolation with LAPW point-by-point ablation and PVI in persistent AF on 12-month arrhythmia-free survival and procedure complications. Methods 77 consecutive patients who underwent LAPW box isolation, 24 patients who underwent LAPW point-by-point ablation and 101 patients who underwent PVI for persistent AF were compared. All patients had undergone no prior ablation for AF and were followed up for one year. Results Mean time to atrial tachyarrhythmia recurrence was similar with LAPW box isolation (9.8 months, 95% CI = 9-10.7) and LAPW point-by-point ablation (10 months, 95% CI = 8.6-11.3), both were longer than PVI (8.2 months, 95% CI = 7.4-9.1, log-rank p = 0.003). There was no difference in peri-procedural complications (LAPW box isolation: 5/77, LAPW point-by-point ablation: 1/24, PVI: 6/101, p = 0.91). At 12 months, no difference in atrial tachyarrhythmia recurrence was observed between box isolation (23/77, 30%) and point-bypoint ablation (11/24, 46%, p = 0.15), but significantly higher recurrence occurred with PVI alone (58/101, 57%, p < 0.001). Procedure time was similar with both approaches, with longer fluoroscopy with point-by-point ablation (median: 38 min, IQR: 29-47.75) vs box isolation (median: 28 min, IQR: 7.5-39.5, p = 0.2). Conclusion In persistent AF, there was no difference between LAPW box isolation and point-by-point ablation in terms of mean arrhythmia-free survival, 12-month recurrence or procedure complications. Arrhythmia-free survival with either technique was longer than PVI alone, with no increase in complications.

Recovery of conduction following high power short duration approach in radiofrequency catheter ablation for atrial fibrillation: a single-center experience

Introduction High-power short-duration (HPSD) ablation is currently being adopted by many as the preferred procedural technique in atrial fibrillation (AF). However, the optimal duration of energy delivery to successfully create a durable lesion is not clear yet. Purpose We evaluated the association of electrical reconnection with lesion-duration in HPSD ablation. Methods Consecutive AF patients undergoing repeat procedure after a prior HPSD ablation with or without isolation of left atrial appendage (LAA) and coronary sinus (CS) were included in this analysis. HPSD ablation was defined as ablation with maximum temperature setting at 420C and power delivery at 45 W for 10–15 sec (5 seconds in the CS area and posterior wall near the esophagus). In some patients a mechanical esophageal deviation tool was used to deflect the esophagus away from the ablation site. Results A total of 2249 AF patients (with LAA and CS isolation: 1451; without LAA and CS isolation: 798) receiving redo ablation after a prior HPSD procedure were included in the analysis. At the prior procedure with the HPSD approach, mean duration of ablation was significantly shorter in the area facing the esophagus compared to elsewhere (5.2±1.5 vs 12.5±1.7 seconds, p<0.001). Application duration was reduced to <10 sec to avoid overheating and steam pops in 1221 (84%) patients receiving LAA and CS isolation. At the redo, recovery of conduction was noted in the CS (592, 40.8%), LAA (493, 34%), and PV and left atrial posterior wall (LAPW) (310, 13.8%). Of the 310 patients with LAPW reconnection, 91% (n=282) had the conduction recovered in the area facing the esophagus. In 73 patients, esophageal displacement device was used during the prior HPSD ablation. Average duration of ablation lesions in LAPW among those 73 patients was 9.2±2 seconds. PV-LAPW reconnection was observed in 3/73 (4.1%) patients. Conclusion HPSD ablation with lesion duration of <10 sec was associated with conduction recovery in the LAA, CS and the LAPW area facing esophagus. FUNDunding Acknowledgement Type of funding sources: None.