Posterior wall isolation using the cryoballoon in conjunction with pulmonary vein ablation is superior to pulmonary vein isolation alone in patients with persistent atrial fibrillation: A multicenter experience

      Background

      Pulmonary vein isolation (PVI) in conjunction with isolation of the posterior left atrial wall (PVI+PWI) is associated with improved clinical outcomes in certain patients with atrial fibrillation (AF).

      Objective

      The purpose of this multicenter study was to evaluate the acute and long-term outcomes of PVI+PWI vs PVI alone performed using cryoballoon ablation in patients with persistent AF (persAF).

      Methods

      We examined the procedural safety and efficacy and short- and long-term outcomes in 390 consecutive patients with persAF who underwent a first-time cryoballoon ablation procedure using PVI+PWI (n = 222 [56.9%]) vs PVI alone (n = 168 [43.1%]).

      Results

      Acute isolation was achieved in 99.7% of all pulmonary veins (PVI+PWI = 99.8% vs PVI alone = 99.3%; P = .23) using 6.3 ± 1.4 applications and 17 ± 2 minutes of cryoablation. PWI was achieved using 13.7 ± 3.2 applications and 34 ± 10 minutes of cryoablation. Adjunct radiofrequency ablation was required in 1.8% of patients to complete PVI (4 ± 2 minutes) and in 32.4% to complete PWI (5 ± 2 minutes). PVI+PWI yielded significantly greater posterior wall (77.2% ± 6.4% vs 40.6% ± 4.9%; P < .001) and total left atrial (53.3% ± 4.2% vs 36.3% ± 3.8%; P < .001) isolation. In addition, PVI+PWI was associated with greater AF termination (19.8% vs 8.9%; P = .003) and conversion to atrial flutters (12.2% vs 5.4%; P = .02). Adverse events were similar in both groups, whereas recurrence of AF and all atrial arrhythmias was lower with PVI+PWI at 12 months of follow-up. Moreover, in a Cox regression analysis, PVI+PWI emerged as a significant predictor of freedom from recurrent atrial arrhythmias (hazard ratio: 2.04; 95% confidence interval: 1.15–3.61; P = .015).

      Conclusion

      PVI+PWI can be achieved safely and effectively using the cryoballoon. This approach appears superior to PVI alone in patients with persAF.

      Keywords

      To read this article in full you will need to make a payment
      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Brooks A.G.
        • Stiles M.K.
        • Laborderie J.
        • Lau D.H.
        • Kuklik P.
        • Shipp N.J.
        • Hsu L.F.
        • Sanders P.
        Outcomes of long-standing persistent atrial fibrillation ablation: a systematic review.
        Heart Rhythm. 2010; 7: 835-846
        • Haïssaguerre M.
        • Jaïs P.
        • Shah D.C.
        • Takahashi A.
        • Hocini M.
        • Quiniou G.
        • Garrigue S.
        • Le Mouroux A.
        • Le Métayer P.
        • Clémenty J.
        Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins.
        N Engl J Med. 1998; 339: 659-666
        • Segerson N.M.
        • Daccarett M.
        • Badger T.J.
        • et al.
        Magnetic resonance imaging-confirmed ablative debulking of the left atrial posterior wall and septum for treatment of persistent atrial fibrillation: rationale and initial experience.
        J Cardiovasc Electrophysiol. 2010; 21: 126-132
        • Cutler M.J.
        • Johnson J.
        • Abozguia K.
        • Rowan S.
        • Lewis W.
        • Costantini O.
        • Natale A.
        • Ziv O.
        Impact of voltage mapping to guide whether to perform ablation of the posterior wall in patients with persistent atrial fibrillation.
        J Cardiovasc Electrophysiol. 2016; 27: 13-21
        • Proietti R.
        • Santangeli P.
        • Di Biase L.
        • Joza J.
        • Bernier M.L.
        • Wang Y.
        • Sagone A.
        • Viecca M.
        • Essebag V.
        • Natale A.
        Comparative effectiveness of wide antral versus ostial pulmonary vein isolation: a systematic review and meta-analysis.
        Circ Arrhythm Electrophysiol. 2014; 7: 39-45
        • Bai R.
        • Di Biase L.
        • Mohanty P.
        • et al.
        Proven isolation of the pulmonary vein antrum with or without left atrial posterior wall isolation in patients with persistent atrial fibrillation.
        Heart Rhythm. 2016; 13: 132-140
        • McLellan A.J.A.
        • Prabhu S.
        • Voskoboinik A.
        • Wong M.C.G.
        • Walters T.E.
        • Pathik B.
        • Morris G.M.
        • Nisbet A.
        • Lee G.
        • Morton J.B.
        • Kalman J.M.
        • Kistler P.M.
        Isolation of the posterior left atrium for patients with persistent atrial fibrillation: routine adenosine challenge for dormant posterior left atrial conduction improves long-term outcome.
        Europace. 2017; 19: 1958-1966
        • Ho S.Y.
        • Cabrera J.A.
        • Sanchez-Quintana D.
        Left atrial anatomy revisited.
        Circ Arrhythm Electrophysiol. 2012; 5: 220-228
        • Jalife J.
        Rotors and spiral waves in atrial fibrillation.
        J Cardiovasc Electrophysiol. 2003; 14: 776-780
        • Nagashima K.
        • Okumura Y.
        • Watanabe I.
        • et al.
        Hot balloon versus cryoballoon ablation for atrial fibrillation: lesion characteristics and efficacy.
        Circ Arrhythm Electrophysiol. 2018; 11: e005861
        • Reddy V.Y.
        • Sediva L.
        • Petru J.
        • Skoda J.
        • Chovanec M.
        • Chitovova Z.
        • Di Stefano P.
        • Rubin E.
        • Dukkipati S.
        • Neuzil P.
        Durability of pulmonary vein isolation with cryoballoon ablation: results from the SUstained PV Isolation with ARctic Front Advance (SUPIR) study.
        J Cardiovasc Electrophysiol. 2015; 26: 493-500
        • Aryana A.
        • Kenigsberg D.N.
        • Kowalski M.
        • Koo C.H.
        • Lim H.W.
        • O’Neill P.G.
        • Bowers M.R.
        • Hokanson R.B.
        • Ellenbogen K.A.
        • Cryo-DOSING Investigators
        Verification of a novel atrial fibrillation cryoablation dosing algorithm guided by time-to-pulmonary vein isolation: results from the Cryo-DOSING Study (Cryoballoon-ablation DOSING Based on the Assessment of Time-to-Effect and Pulmonary Vein Isolation Guidance).
        Heart Rhythm. 2017; 14: 1319-1325
        • Corradi D.
        • Callegari S.
        • Maestri R.
        • et al.
        Differential structural remodeling of the left-atrial posterior wall in patients affected by mitral regurgitation with or without persistent atrial fibrillation: a morphological and molecular study.
        J Cardiovasc Electrophysiol. 2012; 23: 271-279
        • Roberts-Thomson K.C.
        • Stevenson I.
        • Kistler P.M.
        • Haqqani H.M.
        • Spence S.J.
        • Goldblatt J.C.
        • Sanders P.
        • Kalman J.M.
        The role of chronic atrial stretch and atrial fibrillation on posterior left atrial wall conduction.
        Heart Rhythm. 2009; 6: 1109-1117
        • Markides V.
        • Schilling R.J.
        • Ho S.Y.
        • Chow A.W.
        • Davies D.W.
        • Peters N.S.
        Characterization of left atrial activation in the intact human heart.
        Circulation. 2003; 107: 733-739
        • Suenari K.
        • Chen Y.C.
        • Kao Y.H.
        • Cheng C.C.
        • Lin Y.K.
        • Chen Y.J.
        • Chen S.A.
        Discrepant electrophysiological characteristics and calcium homeostasis of left atrial anterior and posterior myocytes.
        Basic Res Cardiol. 2011; 106: 65-74
        • Pison L.
        • La Meir M.
        • van Opstal J.
        • Blaauw Y.
        • Maessen J.
        • Crijns H.J.
        Hybrid thoracoscopic surgical and transvenous catheter ablation of atrial fibrillation.
        J Am Coll Cardiol. 2012; 60: 54-61
        • Lim T.W.
        • Koay C.H.
        • See V.A.
        • McCall R.
        • Chik W.
        • Zecchin R.
        • Byth K.
        • Seow S.C.
        • Thomas L.
        • Ross D.L.
        • Thomas S.P.
        Single-ring posterior left atrial (box) isolation results in a different mode of recurrence compared with wide antral pulmonary vein isolation on long-term follow-up: longer atrial fibrillation-free survival time but similar survival time free of any atrial arrhythmia.
        Circ Arrhythm Electrophysiol. 2012; 5: 968-977
        • Reddy V.Y.
        • Neuzil P.
        • D’Avila A.
        • Ruskin J.N.
        Isolating the posterior left atrium and pulmonary veins with a “box” lesion set: use of epicardial ablation to complete electrical isolation.
        J Cardiovasc Electrophysiol. 2008; 19: 326-329
        • Higuchi S.
        • Sohara H.
        • Nakamura Y.
        • Ihara M.
        • Yamaguchi Y.
        • Shoda M.
        • Hagiwara N.
        • Satake S.
        Is it necessary to achieve a complete box isolation in the case of frequent esophageal temperature rises? Feasibility of shifting to a partial box isolation strategy for patients with non-paroxysmal atrial fibrillation.
        J Cardiovasc Electrophysiol. 2016; 27: 897-904
        • Okumura Y.
        • Watanabe I.
        • Iso K.
        • et al.
        Mechanistic insights into durable pulmonary vein isolation achieved by second-generation cryoballoon ablation.
        J Atr Fibrillation. 2017; 9: 1538
        • Heeger C.H.
        • Tscholl V.
        • Wissner E.
        • et al.
        Acute efficacy, safety, and long-term clinical outcomes using the second-generation cryoballoon for pulmonary vein isolation in patients with a left common pulmonary vein: a multicenter study.
        Heart Rhythm. 2017; 14: 1111-1118
        • Ströker E.
        • Takarada K.
        • de Asmundis C.
        • et al.
        Second-generation cryoballoon ablation in the setting of left common pulmonary veins: procedural findings and clinical outcome.
        Heart Rhythm. 2017; 14: 1311-1318
        • Kuniss M.
        • Greiß H.
        • Pajitnev D.
        • Akkaya E.
        • Deubner N.
        • Hain A.
        • Bodammer L.
        • Berkowitsch A.
        • Chierchia G.B.
        • Hamm C.W.
        • Neumann T.
        Cryoballoon ablation of persistent atrial fibrillation: feasibility and safety of left atrial roof ablation with generation of conduction block in addition to antral pulmonary vein isolation.
        Europace. 2017; 19: 1109-1115
        • Yorgun H.
        • Canpolat U.
        • Kocyigit D.
        • Çöteli C.
        • Evranos B.
        • Aytemir K.
        Left atrial appendage isolation in addition to pulmonary vein isolation in persistent atrial fibrillation: one-year clinical outcome after cryoballoon-based ablation.
        Europace. 2017; 19: 758-768
        • Chun K.J.
        • Ouyang F.
        • Schmidt B.
        • Kuck K.H.
        Focal atrial tachycardia originating from the right atrial appendage: first successful cryoballoon isolation.
        J Cardiovasc Electrophysiol. 2009; 20: 338-341