The absence of real-time pulmonary vein isolation during cryoballoon ablation is associated with atrial fibrillation recurrence and pulmonary vein reconnection : Insights from the Middelheim-PVI Registry 2.

BACKGROUND: Absence of real-time pulmonary vein (PV) isolation (PVI) occurring in 15-40% of PVs during cryoballoon ablation (CBA) of atrial fibrillation (AF) raises doubt about adequate PVI. Aim of the present study is to determine whether real-time PVI during CBA is predictive of long-term clinical outcome and durability of PVI. METHODS: Eight hundred three AF patients (64 ± 10 years, 68% males) undergoing CBA were studied. The cohort was divided in 4 groups according to the number of PVs without real-time PVI: none (N = 252 [31.4%]), 1 (N = 255 [31.8%]), 2 (N = 159 [19.8%]), and 3-4 (N = 137 [17.1]). RESULTS: At 3 years, 279 (34.7%) patients had recurrence of AF of which 188 underwent repeat ablation. A vein without real-time PVI was associated with AF recurrence (HR = 1.275; 95% CI 1.134-1.433; p < 0.01), independent of persistent AF type (HR = 2.075; 95% CI 1.584-2.738; p < 0.01), left atrial diameter (HR = 1.050; 95% CI 1.028-1.072; p < 0.01), and diagnosis-to-ablation time (HR = 1.002; 95% CI 1.000-1.005; p = 0.04). Highest success was achieved with present real-time PVI in all veins (77.4%), gradually decreasing per increasing number of absent real-time PVI: 66.3% for 1 vein, 58.5% for 2, and 48.9% for 3-4 veins (p < 0.001). At repeat ablation (N = 188), PV reconnection was seen in 99/430 (23.0%) versus 83/288 (28.8%) veins with and without real-time PVI, respectively (p = 0.08). Right inferior PVs (RIPVs) with real-time PVI were less reconnected than RIPVs without real-time PVI: 29.7% versus 43.7% (p = 0.047). CONCLUSION: The absence of real-time PVI during CBA independently predicts AF recurrence with a 30% gradual decrease in outcome per increase in veins without real-time PVI. Real-time PVI is particularly important for the RIPV to achieve durable PVI.

Diagnosis-to-ablation time as a predictor of success: early choice for pulmonary vein isolation and long-term outcome in atrial fibrillation: results from the Middelheim-PVI Registry.

Aims: The aim of the study is to define long-term outcome of pulmonary vein isolation (PVI) in atrial fibrillation (AF) and to determine whether time window between AF diagnosis and PVI affects outcome. Methods and results: Consecutive AF patients undergoing PVI (2006-14) were followed for 5 years. Primary outcome was clinical success, defined as freedom of documented AF without anti-arrhythmic drugs respecting a 1-month blanking period. A 1000 patients were included (age 60 ± 10 years, CHA2DS2-VASc score 1 ± 1). The cohort was divided in four quartiles (Q) according to the diagnosis-to-ablation time (DAT): Q1 DAT 0-11 months (N = 244), Q2 DAT 12-≤33 months (N = 254), Q3 DAT 34-≤70 months (N = 252) and Q4 DAT 71-360 months (N = 250). Mean follow-up was 44.3±21.0 months. At 5 years, clinical success was achieved in 45.2 ± 2.0% of patients. Independent predictors of clinical success were AF type (HR = 0.61; 95%CI 0.50-0.74; P < 0.0001), left atrial size (HR = 1.03; 95%CI 1.02-1.05; P < 0.0001), DAT (HR = 1.00; 95%CI 1.00-1.00; P = 0.001), ablation technique (P = 0.012), and year of ablation (HR = 0.93; 95%CI 0.86-1.00; P = 0.045) in multivariable-adjusted analysis. The highest clinical success was achieved when PVI was performed within the first year, and gradually declined with increasing DAT: 55.9 ± 4.6% for Q1, 46.9 ± 4.0% for Q2, 45.5 ± 3.6% for Q3, and 35.5 ± 3.6% for Q4 (P < 0.001). Conclusion: Long-term success rate of PVI is 45.2 ± 2.0%. Shorter diagnosis-to-ablation times are associated with better clinical success. Our data advocate for early PVI following diagnosis of AF.

Retrograde access of the left atrium for pulmonary vein isolation using magnetic navigation after closure of an atrial septum defect.

Transseptal puncture is the most commonly used technique to perform electrophysiological procedures in the left atrium. This case report describes a pulmonary vein isolation in a patient with a paroxysmal atrial fibrillation, complicated by the presence of an oversized Amplatzer device (AGA Medical Corp., Golden Valley, MN). A retrograde approach using the magnetic navigation system (Niobe, Stereotaxis Inc., St Louis, USA) was performed, and showed to provide a feasible, safe and successful alternative for catheter ablation of cardiac arrhythmias in patients in whom the classic transseptal approach is impossible.

Duty-cycled multi-electrode radiofrequency vs. conventional irrigated point-by-point radiofrequency ablation for recurrent atrial fibrillation: comparative 3-year data.

AIMS: Pulmonary vein isolation (PVI) is an accepted treatment to relieve symptoms in patients with atrial fibrillation (AF). We studied 3 year outcome after PVI guided by duty-cycled multi-electrode radiofrequency (RF) ablation (pulmonary vein ablation catheter, PVAC) and provided comparative data to outcome after conventional PVI (CPVI) using mapping with irrigated, point-per-point RF ablation. METHODS AND RESULTS: One hundred and sixty-one consecutive patients with symptomatic paroxysmal or persistent AF and minimal heart disease underwent PVI (PVAC, n = 79 vs. CPVI, n = 82). Follow-up (with symptom-guided rhythm monitoring) was truncated at 3 years in all patients. Success was defined as freedom of documented arrhythmia after a single procedure and without antiarrhythmic drug treatment (ADT). Baseline characteristics did not differ between both groups. At 3 years follow-up, single-procedure success without ADT was comparable between PVAC and CPVI (65% vs. 55%, P = NS). The majority of recurrences occurred during the first year (PVAC 79% vs. CPVI 70%, P = NS). The annual rate of very late recurrence (i.e. beyond 1 year) was similar in both groups (10.5% vs. 15%, P = NS). CONCLUSION: At 3 years follow-up, outcome after PVAC-guided PVI is comparable to conventional isolation by irrigated point-by-point RF ablation. In both strategies, the majority of recurrences occurred in the first year of ablation.