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

BACKGROUND: Left atrial posterior wall isolation (LAPWI) is often performed in addition to pulmonary vein isolation (PVI) in the setting of persistent atrial fibrillation (AF) ablation. The aim of this study was to evaluate the feasibility and safety of a new cryoballoon ablation system in achieving PVI + LAPWI isolation. 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 left posterior wall isolation (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 both groups, except for lower temperatures during cryoenergy in the POLARx group, for both pulmonary vein isolation (PVI) and LAPWI. CONCLUSION: LAPWI + PVI with the novel POLARx™ Cryoballoon is feasible and safe; the results are comparable with the Arctic Front Advance PRO™ system.

Single procedural outcomes in the setting of percutaneous ablation for persistent atrial fibrillation: a propensity-matched score comparison between different strategies.

BACKGROUND: Catheter ablation for persistent atrial fibrillation (persAF) is associated with less favorable outcomes than for paroxysmal AF. To improve success rates, left atrial (LA) substrate modification is frequently performed in addition to pulmonary vein isolation (PVI). The purpose of the study was to compare 4 different ablation approaches using radiofrequency catheter ablation (RFCA) or cryoballoon ablation (CB-A) for persAF and to evaluate the respective outcomes on a midterm follow-up of 12 months. METHODS: We did a propensity score-matched comparison of 30 patients undergoing PVI + LA posterior wall isolation (LAPWI) with CB-A, 30 patients who underwent PVI + linear ablation (roof and mitral lines) using RFCA, 60 patients with PVI alone using CB-A, and 60 patients who had PVI alone using RFCA. The endpoint was recurrence of documented atrial tachyarrhythmias (ATas) > 30 s at 1-year follow-up. RESULTS: After 12 months, freedom from ATas after a single procedure was 83.3% in the PVI + LAPWI group, 46.7% in the PVI + linear ablation group, 58.3% in the PVI-alone CB-A group, and 61.6% PVI-alone RFCA (p = 0.03). Moreover, freedom from ATas was significantly higher comparing the PVI + LAPWI group with each of the other groups. CONCLUSIONS: In this propensity-matched comparison of strategies for persAF, LAPW ablation in addition to PVI with CB-A seems to improve 1-year outcome in comparison to PVI + linear ablation using RFCA and to PVI alone using RFCA or CB-A. Randomized comparisons are eagerly awaited.

Lean Perspectives in an Organizational Change in a Scientific Direction of an Italian Research Institute: Experience of the Cancer Institute of Bari.

Lean management is a relatively new organizational vision transferred from the automotive industry to the healthcare and administrative sector based on analyzing a production process to emphasize value and reduce waste. This approach is particularly interesting in a historical moment of cuts and scarcity of economic resources and could represent a low-cost organizational solution in many production companies. In this work, we analyzed the presentation and the initial management of current ministerial research projects up to the approval by the Scientific Directorate of an Italian research institute. Furthermore, the initial mode in 2021 ("as is") and the potential mode ("to be") according to a Lean model are studied, according to the current barriers highlighted by the final users of the process and carrying out some perspective analyses with some reference indicators.

High vagal tone predicts pulmonary vein reconnection after cryoballoon ablation for paroxysmal atrial fibrillation.

BACKGROUND: Pulmonary vein (PV) isolation is an established treatment for paroxysmal drug-refractory atrial fibrillation (AF). High parasympathetic tone and reconnection of PVs have demonstrated to be possible culprits of AF recurrence after ablation. Our aim was to investigate the association between parasympathetic tone and reconnected PVs in patients with paroxysmal AF. METHODS: Consecutive patients who underwent a redo catheter ablation procedure for atrial tachyarrhythmia recurrence by means of 3D electroanatomic mapping with documentation of presence or absence of PVs reconnection following an initial procedure of cryoballoon (CB) ablation for symptomatic drug-refractory paroxysmal AF were screened for the study. RESULTS: A total of 92 patients were included, of whom 50 (54.35%) were males. Reconnected PVs were found in 64 (69%) patients. PVs reconnection could be predicted by DC (C-statistic = .770), by SDNNI (C-statistic = .714) and by absolute VLF power (C-statistic = .722), while right-sided PVs reconnection could be better predicted by DC (C-statistic = .848) and by SDNNI (C-statistic = .761). In multivariate binary logistic regression analysis, a DC value ≥6.45 ms and an absolute VLF power value ≥160 ms2 were associated with three times and five times higher odds of PVs reconnection, respectively. On a vein-per-vein analysis, absolute VLF power ≥160 ms2 was associated with three times higher odds, while reaching of -40°C within 60 s was associated with three times lower odds of PVs reconnection. CONCLUSION: High parasympathetic tonus accurately predicts PVs reconnection. On a vein-per-vein analysis, parasympathetic markers along with biophysical parameters predicted PVs reconnection. On a case-by-case analysis, parasympathetic markers were the only predictors of PVs reconnection, thus being a robust PVs reconnection prediction tool.

Comparison between superior vena cava ablation in addition to pulmonary vein isolation and standard pulmonary vein isolation in patients with paroxysmal atrial fibrillation with the cryoballoon technique.

BACKGROUND: Paroxysmal atrial fibrillation (PAF) can be triggered by non-pulmonary vein foci, like the superior vena cava (SVC). The latter is correlated with improved result in terms of freedom from atrial tachycardias (ATs), when electrical isolation of this vessel utilizing radiofrequency energy (RF) is achieved. OBJECTIVES: Evaluate the clinical impact, in patients with PAF, of the SVC isolation (SVCi) in addition to ordinary pulmonary vein isolation (PVI) by means of the second-generation cryoballoon (CB) METHODS: A total of 100 consecutive patients that underwent CB ablation for PAF were retrospectively selected. Fifty consecutive patients received PVI followed by SVCi by CB application, and the following 50 consecutive patients received standard PVI. All patients were followed 12 months. RESULTS: The mean time to SVCi was 36.7 ± 29.0 s and temperature at SVC isolation was - 35 (- 18 to - 40) °C. Real-time recording (RTR) during SVCi was observed in 42 (84.0%) patients. At the end of 12 months of follow-up, freedom from ATs was achieved in 36 (72%) patients in the PVI only group and in 45 (90%) patients of the SVC and PV isolation group (Fisher's exact test p = 0.039, binary logistic regression: p = 0.027, OR = 0.28, 95%CI = 0.09-0.86). In survival analysis, SVC and PV isolation group was also associated with improved freedom from ATs (log-rank test: p = 0.017, Cox regression: p = 0.026, HR = 0.31, 95%CI = 0.11-0.87). CONCLUSION: Superior vena cava isolation with the CB in addition to PVI might improve freedom from ATs if compared to PVI alone at 1-year follow-up.

Long-term clinical outcomes after single freeze cryoballoon ablation for paroxysmal atrial fibrillation: a 5-year follow-up.

BACKGROUND: The second-generation cryoballoon ablation (CB-A) has been proven to be safe and effective for pulmonary vein (PV) isolation. Little is known regarding the long-term outcome following CB-A ablation for paroxysmal atrial fibrillation (AF). The aim of the study was to evaluate the freedom from atrial arrhythmias during a 5-year follow-up period among consecutive patients having undergone PV isolation with the CB-A for paroxysmal AF METHODS AND RESULTS: A total of 208 consecutive patients having undergone index PV isolation using CB-A (138 males, 66%; mean age 59.0 ± 12.6 years) were included in our retrospective analysis. Follow-up was based on outpatient clinic visits including Holter electrocardiograms. Recurrence of atrial tachyarrhythmias was defined as a symptomatic or documented episode of > 30 s. At a median follow-up of 62 months, freedom from atrial arrhythmias after a single procedure was achieved in 57.2% of patients. Multivariate analysis demonstrated that obesity, left atrial diameter, and duration of symptoms before AF ablation were independent predictors of ATas recurrences. Major complications occurred in 2.4% of patients. CONCLUSIONS: The present study found a 5-year single-procedure success rate of 57.2% following CB-A ablation procedure. Obesity, higher LA dimensions, and longer duration of symptoms before ablation independently predicted the outcome.

Temperature-guided ablation with the second-generation cryoballoon for paroxysmal atrial fibrillation: 3-year follow-up in a multicenter experience.

PURPOSE: A strategy based on the attainment of the specific parameter of - 40 °C within the first 60 s during cryoenergy applications in the setting of cryoballoon ablation (CB-A) without the use of an inner lumen mapping catheter (ILMC) (Achieve; Medtronic, USA) for the visualization of real-time recordings (RTR) has been previously described. The latter has proven to be very effective in guaranteeing freedom from atrial arrhythmias in patients affected by paroxysmal atrial fibrillation (PAF) at 1-year follow-up. The purpose of this retrospective observational study was to evaluate the clinical outcomes of this strategy in a multicenter experience on a long-term follow-up of 3 years. METHODS: A total of 192 patients having undergone CB ablation for paroxysmal AF (PAF) starting from September 2015 to November 2016 that underwent a temperature-guided approach were included. RESULTS: Mean procedural time was 68.77 ± 18.88. The mean number of freezes in the LSPV was 1.2 ± 0.4, 1.2 ± 0.4 in the LIPV, 1.1 ± 0.4 in the RSPV, and 1.2 ± 0.4 in the RIPV. Considering a blanking period of 3 months, freedom from AF off-AAD was achieved in 77.6% (149/192) at mean 34.5 ± 5.5 months and median 35.1 months (IQR, 32.3-37.0 months) follow-up after 1 procedure. CONCLUSIONS: A temperature-guided approach affords freedom from AF at a 3-year follow-up period in a large majority of patients affected by PAF having undergone a single CB-A procedure.

Safety and feasibility of electrical isolation of the superior vena cava in addition to pulmonary vein ablation for paroxysmal atrial fibrillation using the cryoballoon: lessons from a prospective study.

PURPOSE: The purpose of this study was to evaluate the feasibility and safety of superior vena cava (SVC) isolation in addition to standard pulmonary vein isolation (PVI) using the second-generation cryoballoon (CB) in patients with paroxysmal atrial fibrillation. METHODS: Thirty-seven consecutive patients that underwent CB ablation for paroxysmal atrial fibrillation (PAF) were prospectively enrolled in our study. After PVI the SVC was mapped for potentials. If the SVC exhibited electrical activity, isolation was achieved performing a single 180-s balloon application. RESULTS: Regarding SVC isolation, 180-s freeze in the SVC could be completed in 32 (86.4%) patients, and 5 patients had at least 120 s of freezing application (13.5%). Real-time recording during SVC isolation was observed in 30 (81.0%) patients. The mean time to isolation was 36.9 ± 28.7 s and the temperature at isolation was - 33 (- 15 to - 40) °C. No cases developed persistent phrenic nerve palsy (PNP) or any other complication. CONCLUSIONS: Superior vena cava isolation proved to be safe and feasible with the second generation cryoballoon in a prospective series of patients affected by PAF.

Electrophysiological findings in patients with isolated veins after cryoablation for paroxysmal atrial fibrillation.

AIMS: The main cause of atrial fibrillation recurrence after catheter ablation is pulmonary vein reconnection. The purpose of this retrospective study was to analyse the electophysiological findings in patients undergoing repeat procedures after an index cryoballoon ablation (CB-A) and presenting with permanency of pulmonary vein isolation (PVI) in all veins. In addition, we sought to compare the latter with a similar group of patients with reconnected veins at the redo procedure. METHODS: A total of 132 patients (81 men, 60.7 ±â€Š12.4 years) who underwent CB-A for paroxysmal atrial fibrillation (PAF) were enrolled. Indication for the redo procedure was symptomatic PAF in 83 (63%), persistent atrial fibrillation (PerAF) in 32 (24%) or persistent regular atrial tachycardia (RAT) in 17 (13%) patients. RESULTS: Seventy-five (57%) patients presented a pulmonary vein reconnection (pulmonary vein group) during the redo procedure, whereas 57 (43%) had no pulmonary vein reconnection (non-pulmonary vein group). The non-pulmonary vein group exhibited significantly more non-pulmonary vein foci and atrial flutters than the pulmonary vein group after induction protocol (51 vs. 24%, P = 0.002 and 67 vs. 36%, P = 0.003, respectively). Twenty-two (29.3%) patients of the pulmonary vein group and 20 (35%) patients of the non-pulmonary vein group had atrial fibrillation/RAT recurrence after a mean follow-up of 12.5 ±â€Š8 months. The survival analysis demonstrated no statistical significance in recurrence between both groups (log rank P = 0.358). CONCLUSION: Atrial fibrillation/RAT recurrence in patients after CB-A with durable PVI is significantly associated with non-pulmonary vein foci and atrial flutters. No statistically different success rate regarding atrial fibrillation/RAT freedom was detected between the pulmonary vein and non-pulmonary vein groups after redoing RF-CA.

Predictors of cardiac neuromodulation achieved by cryoballoon ablation performed in patients with atrial fibrillation who were in sinus rhythm before the ablation.

BACKGROUND: The impact of pulmonary vein isolation (PVI) performed with cryoballoon (CB) on the intrinsic cardiac autonomic nervous system (ICANS) remains unclear. OBJECTIVE: The purpose of this study was to evaluate the predictors and the clinical meaning of cardiac neuromodulation achieved by CB-ablation as assessed by sinus heart rate (HR) response after the procedure. METHODS: Patients who underwent CB-ablation for drug-resistant atrial fibrillation (AF) from January 2014 to October 2018 were included. Twelve­leads rest ECG was taken both before and after the procedure. After discharge, patients were scheduled for follow-up visits at 1, 3, 6, and 12 months and 24 h Holter recordings were obtained at each follow-up visit. All documented AF episodes of >30 s were considered as recurrence. RESULTS: Four-hundred seventy-two patients (62.3% male, age 56.7 ± 13.6 years, 97.2% paroxysmal AF) were included. Mean HR before the procedure was 60.17 ± 10.4 bpm, while the morning after the procedure mean HR was 75.48 ± 12.0 bpm. Age at enrollment (R = -0.26; p < 0.001), baseline HR before the CB-A (R = -0.32; p < 0.001), nadir temperature in each right pulmonary vein (R = -0.11, p = 0.022; R = -0.16; p = 0.001) were significantly associated with the ∆HR. At 2-year follow-up, freedom from recurrences was 83.1% for the patients with HR increase ≥15 bpm after CB-A and 66.3% in patients with HR increase ˂15 bpm (p = 0.021). CONCLUSION: Sinus HR increase is a frequent phenomenon after CB-A, that can be predicted by both clinical and procedural factors and that correlates with better outcome after cryo-PVI.

Pulmonary veins anatomical determinants of cooling kinetics during second-generation cryoballoon ablation.

AIM: The aim of the study was to investigate the role of anatomical characteristics of the pulmonary veins (PVs) determining cooling kinetics during second-generation cryoballoon ablation (CbA). METHODS AND RESULTS: we enrolled all consecutive patients who underwent CbA for symptomatic atrial fibrillation in our center from January 2019 to March 2019. All patients had complete computed tomography scans of the heart before the ablation. Anatomical characteristics were tested for prediction of a nadir temperature (NT) ≤ -48°C. Significant differences were noted among PV max diameter (20.8 ± 2.8 vs 18.5 ± 2.5 mm; P < .001); PV minimum diameter (15.2 ± 3.0 vs 13.0 ± 3.1 mm; P < .001); PV area (268.1 ± 71.9 vs 206.2 ± 58.7 mm2 ; P < .001); PV ovality (1.4 ± 0.3 vs 1.5 ± 0.3; P = .005); and PV trunk length (27.4 ± 7.4 vs 21.3 ± 6.5 mm; P < .001). A scoring system was created by assigning one point each ranging from 0 (best anatomical combination) to 5. In the group with a score of 0, 94.0% of the CbA could reach a NT ≤ -48°C whereas with a score of 5, only 29.0% (P < .001). Left superior pulmonary vein with short trunk length and acute angle of PV branch was significantly associated with warmer NT (11.8% satisfactory CbA; P = .003). Regarding right inferior pulmonary vein, trunk length (P = .004), maximum diameter (P = .044), and transverse angle (P = .008) were independently associated with good NT. CONCLUSION: Anatomical PV features are associated with cooling kinetics and an anatomical score could predict lower NT during second-generation CbA. Specific characteristics were identified for inferior PV. Although heart imaging is not mandatory prior CbA, it can be a useful tool to predict cooling kinetics.

Predictors of durable electrical isolation in the setting of second-generation cryoballoon ablation: A comparison between left superior, left inferior, right superior, and right inferior pulmonary veins.

AIM: The aim of this study is to assess specific per-vein procedural predictors of pulmonary vein (PV) late reconnection in cryoballoon ablation (CbA) METHODS AND RESULTS: We enrolled 148 consecutive patients undergoing a redo procedure after a previous index CbA in our center. A reconnection in at least one PV was found in 80 patients (54.1%) and the most frequently reconnected PV was the right inferior pulmonary vein (RIPV). Overall, pulmonary vein reconnection (PVr) was associated with longer time to -40°C (Tt-40°C) (54.4 ± 21.7 vs 67.6 ± 27.6 seconds; P < .001), warmer nadir temperature (NT) (-49.7°C ± 5.4°C vs -46.5°C ± 5.8°C; P < .001) and temperature at 60 seconds (-41.8°C ± 4.5°C vs -39.8°C ± 4.2°C; P < .001). The performance of these predictors differed between the veins. In particular, a comparable behavior was observed for left superior pulmonary vein (LSPV) and right superior pulmonary vein (RSPV), where NT ≤ -48°C showed a sensibility and a specificity, respectively, of 62% and 65% and 71% and 72% in predicting durable PV isolation. For RIPV, NT ≤ -48°C showed a sensitivity of 74% but low specificity (53%). Tt -40°C less than 60 seconds showed good negative predictive values, respectively, 83.9% for LSPV, 94.9% for left inferior pulmonary vein (LIPV), 90.2% for RSPV, and 82.7% for RIPV. Previous predictors cannot be used for LIPV. CONCLUSIONS: Freezing behavior and reconnection rates differ significantly among the four PVs. Freezing temperature parameters strongly predict late PVr in superior PVs and are slightly different in RIPV but can be applied as well. LIPV freezing behavior is the most different. Its reconnection is uncommon even in the subset of worse freezing temperatures and specific CB predictors cannot be identified.

Mid-term outcome following second-generation cryoballoon ablation for atrial fibrillation in heart failure patients: effectiveness of single 3-min freeze cryoablation performed in a cohort of patients with reduced left ventricular systolic function.

PURPOSE: Currently, information on the mid-term outcome of cryoballoon ablation (CB-A) for drug-resistant atrial fibrillation in patients with reduced left ventricular systolic function is limited. METHODS: Thirty-eight consecutive patients with paroxysmal or persistent atrial fibrillation (84.2% male), with median left ventricular ejection fraction of 37.3% were included in our study. All patients underwent the procedure with the 28-mm cryoballoon advance. RESULTS: There were no mayor complications related to the CB-A procedure. Median follow-up was 26.5 ±â€Š13.7 months. The freedom from atrial fibrillation after a blanking period of 3 months was 42.9% in our cohort of patients. During the follow-up period, 13 patients underwent at least a new electrophysiological procedure. After a single procedure, the univariate predictors of clinical recurrence after the blanking period were age and persistent atrial fibrillation. CONCLUSION: Second-generation CB-A of atrial fibrillation seems feasible and safe in patients with heart failure with reduced ejection fraction and heart failure with mid-range ejection fraction, in terms of complications rate and number of applications per vein. All pulmonary veins could be isolated with the 28-mm cryoballoon advance only.

Posterior box isolation as an adjunctive ablation strategy during repeat ablation with the second-generation cryoballoon for recurrence of persistent atrial fibrillation: 1-year follow-up.

BACKGROUND: The creation of a posterior box isolation of the left atrium (LAPWI) in addition to pulmonary vein isolation (PVI) with the second-generation cryoballoon (CB-A) seems to offer promising clinical outcome in patients affected by persistent atrial fibrillation (PersAF). AIM: This work aims to study the clinical outcome of an ablation strategy based on the creation of a LAPWI during repeat procedures for recurrent AF after an index CB-A procedure for PersAF. METHODS AND RESULTS: A total of 33 patients having undergone a repeat procedure consisting in redo PVI plus LAPWI for recurrent PersAF with the CB-A after an index PVI ablation were retrospective included in our study. Electrical reconnection could be documented in 18 veins (13%). The LAPW was successfully isolated solely by CB-A ablation in 30 out of 33 (91%) patients; in the remaining 3 patients, isolation of the LAPW was completed by focal tip-irrigated RF ablation. The mean number of CB-A applications required for the superior portion of the LAPW and the inferior portion of the LAPW creation were 5.4 ± 0.9 and 4 ± 0.6, respectively. After a mean follow-up of 11.8 ± 3 months, 28 patients (85%) did not experience recurrence of any atrial arrhythmias during follow-up, without the need of further ablation or class I or III AADs. CONCLUSION: Left posterior wall isolation with the CB-A is feasible and safe during repeat ablation procedures for recurrent PersAF. In our study, the 12-month freedom from any arrhythmia was 85% following this ablation strategy.

Evaluation of the luminal esophageal temperature behavior during left atrium posterior wall ablation by means of second-generation cryoballoon.

PURPOSE: The purpose of this study was to clarify the behavior of the luminal esophageal temperature (LET) in a cohort of patients undergoing second-generation cryoballoon (CB-A) for pulmonary vein isolation (PVI) and additional left atrium posterior wall (LAPW) ablation by means of CB-A. METHODS: Thirty patients with symptomatic persistent AF (PersAF), having undergone PVI + LAPW cryoballoon ablation with LET monitoring. RESULTS: Interruption of the application due to a LET below 15 °C occurred in 5 patients (16.6%), 2 at the LIPV and 3 in the LAPW. The 5 patients underwent gastroscopy the day after ablation. In all individuals, esophageal thermal lesion (ETL) was absent. CONCLUSION: The evaluation of LET might be an additional tool in helping to prevent damage to the esophagus during the LAPW ablation with the CB-A by stopping the freeze application when temperature reaches values of < 15 °C.

Quantification of acute parasympathetic denervation during cryoballoon ablation by using extracardiac vagal stimulation.

AIMS: The purpose of this study was to systematically quantify the level of acute parasympathetic denervation in a stepwise fashion by means of extracardiac vagal stimulation (ECVS) by positioning a quadripolar catheter in the internal jugular vein, in a cohort of patients undergoing second-generation cryoballoon ablation for paroxysmal atrial fibrillation. METHODS: Fifty patients with symptomatic paroxysmal atrial fibrillation, having undergone extracardiac vagal stimulation before and after ablation by means of second-generation cryoballoon second-generation cryoballoon ablation, were included. RESULTS: The extracardiac vagal stimulation performed preablation provoked cardioinhibitory responses in all patients with mean pause duration of 10130.6 ± 3280.0 ms. At the end of the procedure, the VRs were significantly diminished with mean pause of 1687.5 ms ± 2183.7 ms (P = 0.00 compared with the pause before the procedure). CONCLUSION: The ECVS proved to be a reproducible, feasible and reliable method to quantify the degree of parasympathetic denervation during CB-A. In all patients, significant cardiac parasympathetic denervation could be observed at the end of the procedure. Responses to ECVS were more specific to quantify the vagal denervation than the increase in the heart rate. However larger studies are needed to confirm this observation.

Continuous monitoring after second-generation cryoballoon ablation for paroxysmal atrial fibrillation in patients with cardiac implantable electronic devices.

BACKGROUND: The second-generation cryoballoon (CB) is effective in achieving pulmonary vein isolation. Continuous monitoring would eliminate any over- or underestimated freedom from atrial fibrillation (AF) postablation. OBJECTIVE: The purpose of this study was to differentiate between arrhythmias occurring after cryoballoon ablation (CBA), detecting true AF in symptomatic patients and detecting silent subclinical AF. METHODS: Between June 2012 and January 2015, 54 patients with a preexisting cardiac implantable electronic device (CIED) who had undergone CBA for paroxysmal atrial fibrillation (PAF) were included in our retrospective study. Regular CIED controls, physical examination, and ECG recordings were performed by an experienced cardiologist blinded to the ablation procedure. Data on any hospitalization during follow-up were gathered. Patients were encouraged to note all clinical symptoms during follow-up. RESULTS: Continuous monitoring showed a success rate of 83.3% after 1 year and 75.93% after 3 years of follow-up. During the first year, 68% of episodes of palpitations after ablation were due to sinus tachycardia, nonsustained ventricular tachycardia, or supraventricular tachycardia. AF recurrence was detected in 15.6% of asymptomatic patients during follow-up. Total AF burden post-CBA had decreased to 0.64% ± 4.34% (P <.001) during long-term follow-up of 3.3 years. CONCLUSION: Although this is a selected group of patients with a preexisting CIED, continuous monitoring showed freedom from AF in 83.3% of patients post-CBA after 1 year and 75.93% after 3 years of follow-up.

Hybrid thoracoscopic epicardial ablation of right ventricular outflow tract in patients with Brugada syndrome.

BACKGROUND: Abnormal delayed electrograms (EGMs) from the anterior wall of the right ventricular outflow tract (RVOT) epicardium have become the ablation target in Brugada syndrome (BrS). OBJECTIVE: The aim of this study was to analyze the safety, feasibility, and efficacy of a novel hybrid thoracoscopic approach to perform epicardial RVOT radiofrequency ablation in BrS. METHODS: Thirty-six patients with BrS (26 men (72.2%); mean age 36.6±15.8 years; range 3-63 years) who underwent hybrid thoracoscopic epicardial ablation of RVOT from January 2016 to April 2018 were included in this study. Two expert electrophysiologists analyzed the EGMs during ajmaline challenge and guided the surgeon to perform ablation. Ajmaline challenge was repeated after 1 month to assess the absence of the BrS electrocardiographic pattern. Patients were followed by remote monitoring and outpatient visits every 6 months. RESULTS: The elimination of all abnormal EGMs was achieved in 94.4% of patients. After a mean follow-up of 16 ± 8 months (range 6-30 months), freedom from ventricular arrhythmias was obtained in 7 (77.8%) patients in secondary prevention 9/36 (25%) and in 24 (100%) patients in primary prevention 24/36 (75%). Major complications were observed in 1 patient (2.8%), who experienced late cardiac tamponade. CONCLUSION: Hybrid thoracoscopic epicardial RVOT ablation in BrS is a safe and feasible approach, allowing direct visualization of ablation during radiofrequency delivery. Because of ventricular arrhythmia recurrences, implantable cardioverter-defibrillator implantation is still mandatory in patients treated in secondary prevention and with high risk.

Single 3-min freeze per vein ablation strategy with the second-generation cryoballoon for atrial fibrillation in a large cohort of patients: long term outcome after a single procedure.

PURPOSE: The purpose of the present study was to assess the long-term success rate of a single 3-min freeze per vein ablation strategy in the setting of pulmonary vein isolation (PVI) by means of second-generation cryoballoon (CB-A; Arctic Front Advance, Medtronic, Minneapolis, MN, USA) in a large cohort of patients. METHODS: Three hundred and one patients with drug resistant atrial fibrillation (AF) having undergone PVI by means of CB-A using a single 3-min freeze per vein ablation strategy were included in the analysis. RESULTS: Paroxysmal AF (PAF) was documented in 70.8% of the patients, while 29.2% presented with persistent AF (PersAF). The mean number of CB applications was 1.09 ± 0.3 in the left superior pulmonary vein (LSPV), 1.04 ± 0.2 in the left inferior pulmonary vein (LIPV), 1.12 ± 0.3 in the right superior pulmonary vein (RSPV), and 1.12 ± 0.3 in the right inferior pulmonary vein (RIPV). All PVs were successfully isolated with a 28-mm CB-A only. After a mean follow-up of 38.1 ± 7.5 months, 207 (68.8%) patients were free of atrial tachyarrhythmia (ATa) recurrences following a single procedure. Specifically, 72.8% of patients presenting with PAF and 59.1% of individuals with PersAF did not experience a recurrence. CONCLUSIONS: A single 3-min freeze per vein strategy is effective in treating AF on a long term follow-up of 38 months. Specifically, it can afford freedom from ATa recurrences in 72.8% of patients affected by PAF and 59.1% of patients initially presenting with PersAF after a single CB-A procedure.

Second generation cryoballoon ablation for atrial fibrillation in young adults: midterm outcome in patients under 40 years of age.

Aims: Pulmonary vein isolation (PVI) has been demonstrated more effective in young patients, in which the substrate for atrial fibrillation (AF) is probably more confined to pulmonary vein potentials. The present study sought to focus on the midterm outcomes in patients under 40 years having undergone PVI with the Cryoballoon Advance because of drug resistant AF. Methods and results: Between June 2012 and December 2015, 57 patients having undergone Cryoballoon ablation (CB-A) below 40 years of age for AF in our centre were retrospectively analysed and considered for our analysis. All patients underwent this procedure with the 28 mm Cryoballon Advance. All 227 veins were successfully isolated without the need for additional focal tip ablation. Median follow-up was 18 ±10 months. The freedom from AF after a blanking period of 3 months was 88% in our cohort of patients younger than 40 years old. The most frequent periprocedural complication was related to the groin puncture and occurred in 2 patients. After a single procedure, the only univariate predictor of clinical recurrence was the diagnosis of hypertrophic cardiomyopathy. Conclusion: Young patients affected by AF can be effectively and safely treated with CB-A that grants freedom from AF in 88% of the patients at 18 months follow-up following a 3-month blanking period. All veins could be isolated with the large 28 mm Cryoballoon Advance only.