Cryoballoon Catheter Ablation Research Articles

Outcome after cryoballoon ablation of persistent atrial fibrillation in patients with heart failure with preserved ejection fraction versus tachycardiomyopathy: a propensity score-matched analysis

Abstract Introduction Atrial fibrillation (AF) often coexists with heart failure (HF). The aim of the study was to detect differences in outcome between patients with arrhythmia induced cardiomyopathy (AIC)/tachycardiomyopathy and HFpEF undergoing cryoballoon pulmonary vein isolation (cryo-PVI) using a propensity score-based model. Methods In this retrospective observational study, we analysed persistent AF patients with HFpEF and AIC undergoing cryoballoon ablation between 2014 and 2020. AIC was diagnosed ex juvantibus during the first year after ablation at the 3- and 12-month follow-up when LVEF recovered to > 50% and by more than 10% after ablation and a different aetiology for reduced LVEF was excluded. Propensity score matching was used to pair patients based on their age, sex, CHA2DS2-VASc score and left atrial (LA) area. The primary endpoint was the first documented > 30-s recurrence of atrial arrhythmia after a 3-month blanking period during the one-year follow-up. The secondary endpoints were improvements in NYHA class and reduction of LA area. For identification of independent predictors of atrial arrhythmia recurrence after ablation, univariate and multivariate Cox regression analyses were performed. Results Out of 1293 consecutive patients who underwent cryo-PVI, 148 persistent AF patients with HFpEF and 66 patients with AIC were identified. Propensity score matching yielded 46 patients in each group. HFpEF patients were more symptomatic than AIC patients (NYHA: 2.4 +/- 0.5 vs. 2.0 +/- 0,8; p = 0.002). Other baseline characteristics did not differ between the two groups, except LVEF (57 % [IQR: 52-62%] vs. 41% [QR: 35%-45%]; p= 0.002). Kaplan-Meier curves (Figure 1) demonstrated no difference in recurrence-free survival rate between the groups during the 12-month follow-up (71.7 % vs. 56.5%, log-rank P = 0.16). After the 12-month follow-up, the median LA area decreased significantly in the HFpEF group from 25.8 cm2 (IQR: 23.4-29.5 cm2) to 24.6cm2 (IQR: 22.0-29.6 cm2; p = 0.045) and in the AIC group from 26.6 cm2 (IQR: 22.9-31.1 cm2) to 23.0 cm2 (IQR: 18.3-25.2 cm2; p=0.024). At the 12-month follow-up the median LA-area was significantly higher in the HFpEF than in the AIC cohort (p= 0.007). NYHA class improved significantly in both groups from baseline. At the 1-year follow-up NYHA class was similar between both groups (1.6 +/- 0.8 vs. 1.4 +/- 0,6; p = 0.206). After univariate and multivariate analysis, the following predictors of atrial arrhythmia recurrence were identified: body-mass-index (BMI; HR = 1.082, p = 0.015) and LA area (HR = 1.079, p = 0.003). Conclusions Cryoballoon catheter ablation of persistent AF seems to have similar effectiveness on arrhythmia free survival in patients with HFpEF and AIC. NYHA class and LA enlargement improved after ablation in both groups although LA area in HFpEF was higher than in AIC patients at follow-up. BMI and LA area were identified as predictors of arrhythmia recurrence.

FEASIBILITY AND MICRO–COSTING ANALYSIS OF A SAME–DAY DISCHARGE PROTOCOL FOR CATHETER ABLATION OF ATRIAL FIBRILLATION: A PILOT STUDY USING CRYOBALLOON ABLATION

Abstract Background Catheter ablation (CA) is a well–established treatment for atrial fibrillation (AF). Due to the ageing population, increasing prevalence of AF risk factors, improving detection methods for AF, and broadening indications for ablation, CA for AF is the most common resource–consuming ablation procedure, strongly impacting waiting list times and healthcare costs. The combination of these factors and limited bed availability led to development of a same–day discharge (SDD) protocol with acceptable efficacy and safety outcomes. Due to the COVID–19 outbreak, we started the SDD pilot project to reduce patient hospital stays and time spent on the waiting list. Objective We aimed to assess our day–case service‘s overall effectiveness and safety. Furthermore, we aimed to evaluate the health–economic impact of a routine adoption of day–case AF ablation. Methods Patients with symptomatic and drug–refractory PAF or early Pe–AF scheduled for de–novo ablation were included in the study protocol if they had the following clinical and non–clinical criteria for an SDD protocol: 1–Clinical factors: a) stable anticoagulation, b) No history of bleeding, c) No systolic heart failure, d) No history of pulmonary disease, e) No interventional procedure within 60 days, f) BMI <35, g) CHA DS –VASc ≤3, h) non–severely dilated left atrium, i) age <65 years old; 2–Non–clinical factors: a) home residence within 50 km, or if more, with an emergency department (ER) reachable within 30 minutes, b) home assistance to the patients the same day of the procedure. Results Fifty–two patients were included in the SDD protocol and underwent PVI with the Arctic Front Advance cryoballoon ablation catheter. Patients were admitted to a cardiac short–stay unit on the day of ablation at 7 am. SDD procedures were carried out in conscious sedation without the presence of an anesthesiologist. After ablation, the patient was admitted to the recovery area for at least 6 hours. Postprocedural echocardiography was performed to rule out pericardial effusion. The bed occupancy cost reduction was 493€/procedure with the SDD protocol (2415€ vs. 1921€). No minor or major complications were observed in the SDD protocol. Conclusion The adoption of an optimized path would lead to a reduction in the length of hospital stays, optimization of beds, a reduction in waiting lists, an accelerating patient access to care and a reduction in patient management costs by optimizing the consumption of resources.

Cryoballoon ablation for atrial fibrillation in South Africa: One-year outcome from the Cryo Global Registry

Background. Pulmonary vein isolation (PVI) with cryoballoon catheter ablation (CBA) is a well-established and widely adopted method for the treatment of patients with atrial fibrillation (AF) to prevent recurrences of AF. CBA adoption in South Africa (SA) and outcome data in SA patients are limited.Objectives. To evaluate real-world usage, safety and effectiveness of CBA in SA. Methods. In this sub-analysis of the Cryo Global Registry, 81 participants with paroxysmal AF (PAF) and persistent AF (PsAF) were enrolled between 2017 and 2021 across two private SA hospitals. Baseline characteristics, procedural characteristics, 12-month safety, effectiveness (atrial arrhythmia recurrence), healthcare utilisation (repeat ablation and all-cause hospitalisation), quality of life (QoL; measured by EQ-5D-3L) and predefined symptoms were reported on. Results. Participants in the SA cohort were a mean (standard deviation) of 60 (12) years old, 19 (23.5%) were female, and 48 (59.3%) presented with PAF. The overall presence of baseline comorbidities in the SA cohort was relatively low compared with the entire Cryo Global Registry cohort. The acute PVI success rate was high (98.8%). Two serious procedure-related adverse events occurred in 2 (2.5%) participants in the SA cohort. Freedom from arrhythmia recurrence was 97.4% (95% confidence interval (CI) 83.2 - 99.6%) in PAF and 78.4% (95% CI 58.1 - 89.7%) in persistent AF (p=0.035). Kaplan-Meier estimates for freedom from repeat ablations and all-cause hospitalisations were 97.0% (95% CI 88.4 - 99.2%) and 98.5% (95% CI 90.0 - 99.8%), respectively. Participants reported significant improvement in EQ-5D-3L index score and symptoms from baseline (0.90 (0.11)) - 12 months (0.97 (0.07), p<0.001). Conclusion. CBA standard-of-care procedures in SA resulted in a high clinical freedom from arrhythmia recurrence, with a low risk of safety events within 12 months post ablation. In addition, participants experienced an improvement in QoL and high freedom from healthcare utilisation at 12 months. The obtained results will be important for guiding clinical decisions around CBA in SA.

Novel scoring system derived from meta-analysis and validated in cohort population for predicting 1-year atrial fibrillation recurrence after cryoballoon catheter ablation: The HeLPS-Cryo score.

Atrial fibrillation (AF) recurrence rates in 1 year after cryoballoon ablation catheter (CBCA) are still high. We purposed to identify strong predictors for AF recurrence after the successful CBCA procedure and develop a new scoring system based only on pre-procedural parameters. In the derivation phase, a systematic review and meta-analysis identified the strong predictors of AF recurrence after the CBCA. The pooled hazard ratio (HR) was used to create the new scoring system. The second phase validated the new scoring system in the cohort population. A meta-analysis including 29 cohort studies with 16196 participants confirmed that persistent AF, stroke, heart failure, and left atrial diameter (LAD)>40mm were powerful predictors for AF recurrence after the CBCA procedure. The HeLPS-Cryo (heart failure [1], left atrial dilatation [1], persistent AF [2], and stroke [2]) was developed based on those pre-procedural predictors. It was validated in 140 patients receiving CBCA procedures and revealed excellent predictive performance for 1-year AF recurrence (AUC=0.8877; 95% CI=0.8208 to 0.9546). The HeLPS-Cryo score of ≥3 could predict 1-year AF recurrence with sensitivity and specificity of 78.9% and 87.9%, respectively. The positive predictive value was 66.7%, and the negative predictive value was 93.1%. The HeLPS-Cryo score can help the physician estimate the probability of 1-year AF recurrence after the successful CBCA procedure. Patients with HeLPS-Cryo score<3 are good candidates for the CBCA procedure.

Economic evaluation of first-line cryoballoon ablation versus antiarrhythmic drug therapy for the treatment of paroxysmal atrial fibrillation from an English National Health Service perspective

IntroductionThree recent randomised controlled trials have demonstrated that pulmonary vein isolation as an initial rhythm control strategy with cryoablation reduces atrial arrhythmia recurrence in patients with symptomatic paroxysmal atrial fibrillation...

Coronary artery disease in atrial fibrillation ablation: impact on arrhythmic outcomes.

Catheter ablation (CA) is an established treatment for atrial fibrillation (AF). A computed tomography (CT) may be performed before ablation to evaluate the anatomy of pulmonary veins. The aim of this study is to investigate the prevalence of patients with coronary artery disease (CAD) detected by cardiac CT scan pre-ablation and to evaluate the impact of CAD and revascularization on outcomes after AF ablation. All consecutive patients with AF diagnosis, hospitalized at Universitair Ziekenhuis Brussel, Belgium, between 2015 and 2019, were prospectively screened for enrolment in the study. Inclusion criteria were (i) AF diagnosis, (ii) first procedure of AF ablation with cryoballoon CA, and (iii) contrast CT scan performed pre-ablation. A total of 576 consecutive patients were prospectively included and analysed in this study. At CT scan, 122 patients (21.2%) were diagnosed with CAD, of whom 41 patients (7.1%) with critical CAD. At survival analysis, critical CAD at CT scan was a predictor of atrial tachyarrhythmia (AT) recurrence during the follow-up, only in Cox univariate analysis [hazard ratio (HR) = 1.79] but was not an independent predictor in Cox multivariate analysis. At Cox multivariate analysis, independent predictors of AT recurrence were as follows: persistent AF (HR = 2.93) and left atrium volume index (HR = 1.04). In patients undergoing CT scan before AF ablation, critical CAD was diagnosed in 7.1% of patients. Coronary artery disease and revascularization were not independent predictors of recurrence; thus, in this patient population, AF ablation should not be denied and can be performed together with CAD treatment.

Ablation as First-line Therapy for Atrial Fibrillation.

AF is a chronic and progressive heart rhythm disorder characterised by exacerbations and remissions. Contemporary guidelines recommend antiarrhythmic drugs (AADs) as the initial therapy for the maintenance of sinus rhythm. However, these medications have modest efficacy and are associated with significant adverse effects. Several recent trials have evaluated catheter ablation as an initial therapy for AF, demonstrating that cryoballoon catheter ablation significantly improves arrhythmia outcomes (e.g. atrial tachyarrhythmia recurrence and arrhythmia burden), produces clinically meaningful improvements in patient-reported outcomes (e.g. symptoms and quality of life), and significantly decreases healthcare resource usage (e.g. hospitalisation), without increasing the risk of serious adverse events. Moreover, in contrast to antiarrhythmic drugs, catheter ablation appears to be disease-modifying, significantly reducing the progression of disease. These findings are relevant to patients, providers, and healthcare systems, helping inform the initial choice of rhythm-control therapy in patients with treatment-naïve AF.

Retraction Note: The efficacy and safety of cryoballoon catheter ablation in patients with paroxysmal atrial fibrillation.

Retraction Note: The efficacy and safety of cryoballoon catheter ablation in patients with paroxysmal atrial fibrillation.

Impact of different energy sources on the cardiac autonomic nervous system in the setting of single-shot pulmonary vein isolation

Abstract Funding Acknowledgements Type of funding sources: None. Background The cardiac autonomic nervous system is an epicardial neural network composed of ganglionated plexi (GPs) and interconnecting neurons, which plays a significant role in the induction and maintenance of atrial fibrillation (AF). Targeted GPs ablation in addition to pulmonary vein isolation (PVI) has been associated with superior AF outcomes. Due to the anatomical proximity of the GPs with the pulmonary veins, PVI with cryoballoon catheter ablation (CBA) has shown to concomitantly affect the GPs, as documented by increased heart rates (HR) after ablation. Recently, pulsed-field ablation (PFA) has emerged as a safe and effective non-thermal alternative for single-shot PVI, with specific selectivity for the cardiac tissue. The impact of PFA on the cardiac autonomic nervous system is still to be elucidated. Purpose To assess the effect of PFA on the cardiac autonomic nervous system, evaluated with the variation in resting heart rate pre- and post-ablation. Methods We retrospectively included all consecutive patients with symptomatic paroxysmal AF undergoing first-time PVI with the multispline PFA catheter between January and September 2022. They were compared with consecutive patients undergoing PVI with CBA in the same study period. Patients not in sinus rhythm before ablation or with cardiac implantable electronic devices were excluded. All antiarrhythmic drugs were discontinued at least 3 days before ablation. Pre-ablation and 24-hour post-ablation ECGs in sinus rhythm were collected and analysed to assess HR. Results A total of 90 patients (PFA group, n=30 vs CBA group, n=60) were included in the analysis. Baseline patients’ characteristics were similar between the two groups (Figure 1). Pre-ablation HRs in the PFA and the CBA groups were 64.2 ± 10.3 bpm and 64.2 ± 12.8 bpm, respectively. Vagal reactions during ablation occurred more frequently with PFA than CBA (77% vs 38%, p=0.001). After 24h post-ablation, the HR increase in the PFA and CBA groups was 2.2 ± 5.4 bpm and 12.4 ± 11.9 bpm, respectively (p&amp;lt;0.001, Figure 2). Conclusion PVI with the novel multispline PFA catheter is associated with less increase in HR 24 hours after ablation compared to CBA. This effect may be the result of tissue selectivity of PFA for cardiomyocytes, which has minimal effect on extracardiac structures, including the cardiac autonomic nervous system.

Comparison of pulsed field ablation and cryoballoon ablation in atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Pulmonary vein isolation (PVI) using cryoballoon (CB) catheter ablation has emerged as a cornerstone for treatment of atrial fibrillation (AF). Recently pulsed field ablation (PFA) has been introduced for PVI. First data show high acute and favorable long-term outcome. So far, data comparing these "single shot" devices is sparse. Objective This analysis sought to provide procedural and outcome data comparing PFA to CB PVI. Furthermore, potentially postprocedural discomfort was evaluated. Methods A retrospective analysis of PVI procedures using PFA or CB was performed. Discomfort analysis was obtained by prescribed analgesic medication within first 48 h after PVI (fully digital patient file). During follow-up (FU) repeat outpatient visits and Holter ECG were performed. Results In all 108 patients with AF (54 PFA and 54 CB; PFA: 37 (69 %) men; CB: 38 (70 %) men) successful PVI was achieved. There were no significant differences regarding baseline characteristics. 17 (31 %) patients in the PFA group and 18 (33 %) patients in the CB group had paroxysmal AF. Procedure time trended to be shorter in the PFA group (PFA: 64.5±17.5 minutes; CB: 73.0±24.8 minutes; p=0.07). Sub-analysis of the PFA group revealed a significant shortening of procedure duration over time (first 27 PFA vs. second 27 PFA: 72.9±19.1 minutes vs. 56.1±10.7 minutes, p=0.001). Significantly less contrast medium was used for PFA PVI as compared to CB PVI (PFA: 12± 6 ml; CB: 51± 29 ml, p&amp;lt;0.0001). Fluoroscopy time was significantly longer for PFA PVI (PFA: 15.3±4.7 minutes, CB: 12.3±5.3 minutes; p=0.001). Analysis of postprocedural analgesic medication demand did not differ between PFA and CB PVI (PFA: 7 patients; CB: 10 patients; p=0.59). After a FU of 234±127 days 79% of patients remained in SR after PFA and 78% after CB PVI (p=0.88). In the PFA group 2 non-device related cardiac tamponades occurred. Conclusion A comparison of PFA to CB PVI revealed a comparable efficacy and safety profile with a steep learning curve and potentially shorter procedure duration. Amount of contrast medium is significantly higher for CB PVI. So far, arrhythmia-free survival seems to be still equal between both techniques. However, PFA is a safe and effective alternative to CB for PVI.

PO-04-064 QUANTIFICATION OF AUTONOMIC MODULATION DURING SINGLE-SHOT PULMONARY VEIN ISOLATION WITH PULSED FIELD ABLATION

Additional ganglionated plexi (GPs) ablation beyond pulmonary vein isolation (PVI) has been associated with better outcomes after radiofrequency ablation. Because of the anatomical relationship between the major atrial GPs and the pulmonary veins, single-shot PVI with cryoballoon catheter ablation (CBA) has been demonstrated to concomitantly affect the GPs, as documented by intraprocedural vagal reactions and increased heart rates (HR) after ablation. The novel multispline pulsed field ablation catheter (PFA) is emerging as a safe and effective non-thermal single-shot alternative for PVI, with ablation selectivity for the cardiac tissue. To quantify the degree of parasympathetic denervation during single-shot PVI with PFA compared with CBA. We prospectively included consecutive patients undergoing autonomic modulation assessment with extracardiac vagal stimulation (ECVS) during single-shot PVI for paroxysmal AF with PFA and CBA. Patients with previous ablations were excluded. The response to ECVS was determined as the sinus pause following stimulation, measuring the maximum PP interval (sinus node response). Baseline and post-ablation responses to ECVS were collected and analysed. The degree of autonomic modulation in the two groups was assessed by evaluating the difference between pre- and post-ablation responses to ECVS. A total of 30 patients (PFA group, n=15 vs CBA group, n=15) were included in the analysis. Baseline patients’ characteristics were similar between the two groups (Table 1). Pre-ablation responses to ECVS were similar between the PFA and CBA groups (10757.3 ± 3155.2 ms vs. 11155.9 ± 2472.3 ms, p=0.70). Vagal reactions during PVI occurred more frequently with PFA than CBA (86.7% vs 20%, p=0.001), more commonly during left superior PVI. After PVI, the sinus pause following ECVS was significantly longer after PFA compared with CBA (9897.9 ± 2702.0 ms vs. 874.6 ± 213.6 ms; p<0.001, Figure 1). Despite similar baseline values, 24h post-ablation HR increased significantly more with CBA than PFA (14.0 ± 6.8 bpm vs. 1.8 ± 8.4 bpm, respectively; p<0.001). Single-shot PVI with PFA was associated with less autonomic modulation compared with CBA at ECVS testing. This is likely the result of cardiac tissue selectivity, with minimal effect on the autonomic nervous system. The clinical impact of reduced parasympathetic denervation of PFA on AF outcome is yet to be elucidated.

Prognostic significance of variant left common pulmonary vein after transcatheter pulmonary vein isolation

Left common pulmonary vein is the most common anatomical variant of pulmonary veins that may affect the outcome of pulmonary vein isolation. Our aim was to compare procedural data and outcomes in patients with common trunk versus normal left atrial anatomy for radiofrequency and cryoballoon catheter ablation. Data from patients who underwent pulmonary vein isolation for atrial fibrillation and had a preprocedural cardiac CT scan at our Institution between 01. 10. 2019 and 10. 03. 2022 were retrospectively evaluated. We defined a common trunk where the left superior and inferior pulmonary vein merged at least 5 mm before the left atrial ostium. From the study population (n = 210), data from 42 patients with a left common trunk (LCPV group) and 60 patients with normal left atrial anatomy (control group) were examined. No significant differences were found between the common trunk and the control group in terms of demographic data. There was no significant difference between the two groups in procedural data for radiofrequency and cryoballoon ablation (procedure time, fluoroscopy time, left atrial dwelling time, radiation dose). After radiofrequency ablation, the success rate at 1-year follow-up was 72.0% in the common trunk group and 76.2% in the control group (p = 0.659). For cryoballoon ablation, the success rate was 64.7% and 69.2% for common trunk and normal anatomy, respectively (p = 0.641). There was no significant difference in the procedural parameters and clinical outcome between patients with left common pulmonary vein and those with normal left atrial anatomy. Both radiofrequency and cryoballoon ablation techniques are well suited for this population. Orv Hetil. 2023; 164(4): 140-147.

Integrating the Left Atrium Diameter to Improve the Predictive Ability of the Age, Creatinine, and Ejection Fraction Score for Atrial Fibrillation Recurrence After Cryoballoon Ablation.

Several clinical trials have assessed predictors for atrial fibrillation recurrence following cryoballoon catheter ablation. With these predictors, a practical and new scoring system can be developed to evaluate atrial fibrillation recurrence. The present study aimed to analyze the predictive value of the age, creatinine, and ejection fraction-left atrium score for potential recurrence of atrial fibrillation following cryoballoon catheter ablation in patients with symptomatic paroxysmal or persistent atrial fibrillation. We retrospectively analyzed records of patients undergoing cryoballoon cath-eter ablation. atrial fibrillation recurrence was defined as an emerging atrial fibrillation episode around 12-month follow-up (with the exclusion of a 3-month blanking period). Univariate and multivariate analyses were performed to assess predictors of atrial fibrillation recurrence. In addition, receiver operating characteristic analysis was harnessed to evaluate the performance of the age, creatinine, and ejection fraction, left atrium score in determining the risk of atrial fibrillation recurrence. The study population comprised 106 subjects (age 52 ± 13 years, 63.2% women) with paroxysmal (84.9%, n = 90) or persistent (15.1%, n = 16) atrial fibrillation. age, creatinine, and ejection fraction, left atrium score was significantly higher in subjects with atrial fibrillation recurrence in comparison to those with the maintenance of sinus rhythm. However, on multivariate logistic regression analysis, only the age, creatinine, and ejection fraction, left atrium score (OR = 12.93, 95% CI: 2.22-75.21, P =.004) served as an independent predictor of atrial fibrillation recurrence following cryoballoon catheter ablation. Age, creatinine, and ejection fraction, left atrium score had an independent association with the risk of atrial fibrillation recurrence in subjects with atrial fibrillation undergoing cryoballoon catheter ablation. Therefore, this score might potentially serve as a useful tool for risk stratification of patients with atrial fibrillation.

Association of Uric Acid Albumin Ratio with Recurrence of Atrial Fibrillation after Cryoballoon Catheter Ablation.

Objective: Despite improvements in the technology of catheter ablation of atrial fibrillation (AF), recurrences are still a major problem, even after a successful procedure. The uric acid/albumin ratio (UAR), which is an inexpensive and simple laboratory parameter, has recently been introduced in the literature as a predictor of adverse cardiovascular events. Hence, we aimed to investigate the relationship between the UAR and AF recurrence after catheter ablation. Methods: A total of 170 patients who underwent successful catheter ablation for AF were included. The primary outcome was the late recurrence after treatment. The recurrence (+) and recurrence (-) groups were compared for clinical, laboratory and procedural characteristics as well as the predictors of recurrence assessed by regression analysis. Results: In our study population, 53 (26%) patients developed AF recurrence after catheter ablation. Mean UAR was higher in the recurrence (+) group compared to recurrence (-) group (2.4 ± 0.9 vs. 1.8 ± 0.7, p &lt; 0.01). In multivariable regression analysis, left atrial diameter (HR: 1.08, 95% CI: 1.01-1.16, p = 0.01) and UAR (HR:1.36, 95% CI: 1.06-1.75, p = 0.01) were found to be independent predictors of recurrence. In ROC analysis, the UAR &gt; 1.67 predicted recurrence with a sensitivity of 77% and a specificity of 57% (AUC 0.68, p &lt; 0.01). Conclusion: For the first time in the literature, the UAR were found to be correlated independently with AF recurrence after catheter ablation.

Patient selection, peri-procedural management, and ablation techniques for catheter ablation of atrial fibrillation: an EHRA survey.

Catheter ablation (CA) of atrial fibrillation (AF) is the therapy of choice for the maintenance of sinus rhythm in patients with symptomatic AF. Time towards interventional treatment and peri-procedural management of patients undergoing AF ablation may vary in daily practice. The scope of this European Heart Rhythm Association (EHRA) survey was to report the current clinical practice regarding the management of patients undergoing AF ablation and physician's adherence to the European Society of Cardiology Guidelines and the EHRA/HRS/ECAS expert consensus statement on the CA for AF. This physician-based survey was conducted among EHRA members, using an internet-based questionnaire developed by the EHRA Scientific Initiatives Committee. A total of 258 physicians participated in the survey. In patients with paroxysmal or persistent AF, 42 and 9% of the physicians would routinely perform AF ablation as first-line therapy respectively, whereas 71% of physicians would consider ablation as first-line therapy in patients with symptomatic AF and left ventricular ejection fraction <35%. Only 14% of the respondents manage cardiovascular risk factors in patients referred for CA using a dedicated AF risk factor management programme. Radiofrequency CA is the preferred technology for first-time AF (56%), followed by cryo-balloon CA (40%). This EHRA survey demonstrated a considerable variation in the management of patients undergoing AF ablation in routine practice and deviations between guideline recommendations and clinical practice.

Progression of Atrial Fibrillation after Cryoablation or Drug Therapy

BackgroundAtrial fibrillation is a chronic, progressive disorder, and persistent forms of atrial fibrillation are associated with increased risks of thromboembolism and heart failure. Catheter ablation as initial therapy may modify the pathogenic mechanism of atrial fibrillation and alter progression to persistent atrial fibrillation.MethodsWe report the 3-year follow-up of patients with paroxysmal, untreated atrial fibrillation who were enrolled in a trial in which they had been randomly assigned to undergo initial rhythm-control therapy with cryoballoon ablation or to receive antiarrhythmic drug therapy. All the patients had implantable loop recorders placed at the time of trial entry, and evaluation was conducted by means of downloaded daily recordings and in-person visits every 6 months. Data regarding the first episode of persistent atrial fibrillation (lasting ≥7 days or lasting 48 hours to 7 days but requiring cardioversion for termination), recurrent atrial tachyarrhythmia (defined as atrial fibrillation, flutter, or tachycardia lasting ≥30 seconds), the burden of atrial fibrillation (percentage of time in atrial fibrillation), quality-of-life metrics, health care utilization, and safety were collected.ResultsA total of 303 patients were enrolled, with 154 patients assigned to undergo initial rhythm-control therapy with cryoballoon ablation and 149 assigned to receive antiarrhythmic drug therapy. Over 36 months of follow-up, 3 patients (1.9%) in the ablation group had an episode of persistent atrial fibrillation, as compared with 11 patients (7.4%) in the antiarrhythmic drug group (hazard ratio, 0.25; 95% confidence interval [CI], 0.09 to 0.70). Recurrent atrial tachyarrhythmia occurred in 87 patients in the ablation group (56.5%) and in 115 in the antiarrhythmic drug group (77.2%) (hazard ratio, 0.51; 95% CI, 0.38 to 0.67). The median percentage of time in atrial fibrillation was 0.00% (interquartile range, 0.00 to 0.12) in the ablation group and 0.24% (interquartile range, 0.01 to 0.94) in the antiarrhythmic drug group. At 3 years, 8 patients (5.2%) in the ablation group and 25 (16.8%) in the antiarrhythmic drug group had been hospitalized (relative risk, 0.31; 95% CI, 0.14 to 0.66). Serious adverse events occurred in 7 patients (4.5%) in the ablation group and in 15 (10.1%) in the antiarrhythmic drug group.ConclusionsInitial treatment of paroxysmal atrial fibrillation with catheter cryoballoon ablation was associated with a lower incidence of persistent atrial fibrillation or recurrent atrial tachyarrhythmia over 3 years of follow-up than initial use of antiarrhythmic drugs. (Funded by the Cardiac Arrhythmia Network of Canada and others; EARLY-AF ClinicalTrials.gov number, NCT02825979.)

Cryoballoon catheter ablation or drug therapy to delay progression of atrial fibrillation: A single-center randomized trial.

Delaying atrial fibrillation (AF) progression is a key goal in cardiovascular treatment. However, numbers of previously published studies on delayed AF progression are relatively limited. The purpose of this study was to determine whether a cryoballoon catheter ablation (CA) strategy could delay AF progression compared to anti-arrhythmic drug (AAD) treatment in patients with paroxysmal AF. A total of 204 subjects were enrolled in the trial, including 102 in the cryoballoon CA group and 102 in the AAD group. Participants were followed up with for 36 months. The primary study endpoint was the first occurrence of persistent atrial tachyarrhythmia, while secondary endpoints included the event rates of persistent atrial tachyarrhythmia at 1 and 2 years. The primary safety endpoint was serious adverse events. Overall, the 36-month follow-up was completed by 154 subjects (75.5%). At 3 years, documented progression from paroxysmal AF to persistent atrial tachyarrhythmia had occurred in 2 of the 102 patients assigned to undergo cryoballoon CA [2.203% (95% confidence interval (CI), 0.554-8.537)] and in 17 of the 102 patients assigned to receive AADs [20.223% (95% CI, 13.040-30.604)] [hazard ratio (HR), 0.107; 95% CI, 0.043-0.262; P < 0.001]. Lower rates of progression in the cryoballoon CA group compared to the AAD group were already obvious at 1 year [1.053% (95% CI, 0.149-7.238) vs. 5.284% (95% CI, 2.233-12.237)] [HR, 0.193; (95% CI, 0.039-0.956; P = 0.09)] and 2 years [2.203% (95% CI, 0.554-8.537) vs. 12.430% (95% CI, 7.066-21.371)] (HR, 0.169; 95% CI, 0.057-0.501, P < 0.001). Serious adverse events occurred in 7 of the 102 patients (6.9%) in the cryoballoon CA group and 9 of the 102 patients (8.8%) in the AAD group. Cryoballoon CA was superior to AAD therapy in preventing the occurrence of persistent atrial tachyarrhythmia in patients with paroxysmal AF who had not received prior rhythm control therapy. Serious adverse events were rare.

Cryoballoon ablation for atrial fibrillation: Effects on neuromodulation.

Pulmonary vein isolation (PVI) represents the mainstay of atrial fibrillation (AF) ablation, and PVI with cryoballoon catheter (CB) ablation (CB-A) has proven to be as effective and safe as radiofrequency ablation (RF-A). Although AF is initiated by triggers arising from the pulmonary veins (PV) and non-PV foci, the intrinsic cardiac nervous system (ICNS) plays a significant role in the induction and maintenance of AF. The ICNS is an epicardial neural system composed of ganglionated plexi (GPs) and a complex network of interconnecting neurons. In the left atrium, the major GPs are located in proximity to the PV-left atrial junction. Vagal reactions have been described as markers of autonomic modulation during PVI with both RF-A and CB-A. The occurrence of neuromodulation during PVI with CB-A may be explained by both the anatomical relationship between the GPs and the PVs and the characteristics of the CB. Due to the CB/PV size mismatch, the CB creates a wide ablation area that extends from the PV ostium toward the antrum, possibly including the GPs. Although targeted GPs ablation, as a supplemental strategy to PVI, has been associated with a better AF outcome in patients undergoing RF-A, the additional clinical benefit of neuromodulation during PVI with CB-A remains a matter of debate. In this review, we provide an overview of the anatomy of the ICNS, the relationship between the ICNS and AF pathophysiology, and the current evidence on the clinical relevance of neuromodulation during PVI with CB-A.

Long-Term Outcomes of Pulmonary Vein Isolation in Patients With Brugada Syndrome and Paroxysmal Atrial Fibrillation.

BackgroundPharmacological treatment of atrial fibrillation (AF) in the setting of Brugada syndrome (BrS) is challenging. In addition, patients with BrS with an implantable cardioverter‐defibrillator (ICD) might experience inappropriate shocks for fast AF. Long‐term outcome of pulmonary vein isolation in BrS has not been well established yet, and it is still unclear whether pulmonary vein triggers are the only pathophysiological mechanism of AF in BrS. The aim of the study is to assess the long‐term outcomes in patients with BrS undergoing pulmonary vein isolation for paroxysmal AF compared with a matched cohort of patients without BrS.Methods and ResultsSixty patients with BrS undergoing pulmonary vein isolation with cryoballoon catheter ablation for paroxysmal AF were matched with 60 patients without BrS, who underwent the same procedure. After a mean follow‐up of 58.2±31.7 months, freedom from atrial tachyarrhythmias was achieved in 61.7% in the BrS group and in 78.3% in the non‐BrS group (log‐rank P=0.047). In particular, freedom from AF was 76.7% in the first group and in 83.3% in the second (P=0.27), while freedom from atrial tachycardia/atrial flutter was 85% and 95% (P=0.057). In the BrS group, 29 patients (48.3%) had an ICD and 8 (27.6%) had a previous ICD‐inappropriate shock for fast AF. In the BrS cohort, ICD‐inappropriate interventions for AF were significantly reduced after ablation (3.4% versus 27.6%; P=0.01).ConclusionsPulmonary vein isolation in patients with BrS was associated with higher rate of arrhythmic recurrence. Despite this, catheter ablation significantly reduced inappropriate ICD interventions in BrS patients and can be considered a therapeutic strategy to prevent inappropriate device therapies.

New evidence: Cryoballoon ablation vs. antiarrhythmic drugs for first-line therapy of atrial fibrillation.

Atrial fibrillation (AF) is a commonly encountered chronic and progressive heart rhythm disorder, characterized by exacerbations and remissions. Contemporary clinical practice guidelines recommend a trial of antiarrhythmic drugs (AADs) as the initial therapy for sinus rhythm maintenance; however, these medications have modest efficacy and are associated with significant adverse effects. Recently, several trials have demonstrated that an initial treatment strategy of cryoballoon catheter ablation significantly improves arrhythmia outcomes (e.g. freedom atrial tachyarrhythmia and reduction in arrhythmia burden), produces clinically meaningful improvements in patient-reported outcomes (e.g. symptoms and quality of life), and significantly reduces subsequent healthcare resource utilization (e.g. hospitalization), without increasing the risk of serious or any adverse events. These findings are relevant to patients, providers, and healthcare systems, helping inform the decision regarding the initial choice of rhythm-control therapy in patients with treatment-naïve AF.