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Using the cryoballoon for posterior wall isolation: Thinking inside “the box”

      Catheter ablation for paroxysmal atrial fibrillation (AF) is becoming increasingly common, particularly as success rates improve. In this population, pulmonary vein (PV) isolation (PVI) is the cornerstone of therapy.
      • 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.
      • Calkins H.
      • Hindricks G.
      • Cappato R.
      • et al.
      2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation.
      However, in patients with persistent AF, the optimal lesion set has not been determined. While small studies have demonstrated that additional ablation beyond PVI is associated with decreased AF recurrence, randomized data have not corroborated this notion.
      • Verma A.
      • Jiang C.
      • Betts T.R.
      • et al.
      Approaches to catheter ablation for persistent atrial fibrillation.
      • Tamborero D.
      • Mont L.
      • Berruezo A.
      • Matiello M.
      • Benito B.
      • Sitges M.
      • Vidal B.
      • de Caralt T.M.
      • Perea R.J.
      • Vatasescu R.
      • Brugada J.
      Left atrial posterior wall isolation does not improve the outcome of circumferential pulmonary vein ablation for atrial fibrillation: a prospective randomized study.
      • Kim J.-S.
      • Shin S.Y.
      • Na J.O.
      • et al.
      Does isolation of the left atrial posterior wall improve clinical outcomes after radiofrequency catheter ablation for persistent atrial fibrillation? A prospective randomized clinical trial.
      The combination of PVI and posterior wall isolation (PWI) is an attractive lesion set for a number of reasons. First, data from the surgical literature suggest that isolation of the “box” between the PVs in the posterior wall of the left atrium (LA) is associated with improved outcomes.
      • Voeller R.K.
      • Bailey M.S.
      • Zierer A.
      • et al.
      Isolating the entire posterior left atrium improves surgical outcomes after the Cox maze procedure.
      Second, PWI creates conduction block to prevent potential reentrant circuits. Third, PWI “reinforces” PVI by reducing the potential for small gaps in the posterior aspect of the PVI lesion set that lead to PV conduction recovery. Fourth, PWI debulks the potential substrate or trigger sites for AF initiation or perpetuation, as the posterior wall has been shown to be histologically similar to PV tissue.
      • Cabrera J.A.
      • Ho S.Y.
      • Climent V.
      • Fuertes B.
      • Murillo M.
      • Sánchez-Quintana D.
      Morphological evidence of muscular connections between contiguous pulmonary venous orifices: relevance of the interpulmonary isthmus for catheter ablation in atrial fibrillation.
      • Ho S.Y.
      • Cabrera J.A.
      • Sanchez-Quintana D.
      Left atrial anatomy revisited.
      Finally, PWI may more reliably lead to ablation of ganglionated plexi.
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