Against the background of these remarkable developments, the guidelines needed to undergo many changes and revisions. ...the format has been revised again to include cardiac implantable electronic ...devices and catheter ablation therapies. ...prevention of systemic embolism using a left atrial appendage closure (LAAC) device is being established as a breakthrough treatment for AF patients who have difficulty in continuing anticoagulation therapy. Because early implantable cardioverter-defibrillators (ICDs) were highly invasive owing to the requirement for a thoracotomy, the indications for this treatment were highly limited. In 2004, cardiac resynchronization therapy (CRT) became available for patients with impaired cardiac function, and the usefulness of this treatment has been verified. especially in heart failure patients with complete left bundle branch block in Japan. Because patients with heart failure have a high risk of sudden death, an ICD with a biventricular pacing function (CRT defibrillator CRT-D) was also developed and approved in 2006.
Few data are available on gastric hypomotility (GH) after cryoballoon pulmonary vein isolation. Also, the use of esophageal temperature monitoring for the prevention of endoscopically detected ...esophageal lesions (EDELs) is not well established.
The purpose of this study was to investigate GH and the impact of an esophageal probe on EDELs during second-generation cryoballoon ablation.
One hundred four patients with paroxysmal atrial fibrillation undergoing second-generation cryoballoon ablation under conscious sedation followed by esophagogastroscopy were prospectively included. Temperature probes were used in the first 40 (38.5%) patients, but not in the latter 64 (61.5%). Pulmonary vein isolation was performed with one 28-mm balloon using single 3-minute freeze techniques.
Clinical and procedural characteristics were similar between the groups. Esophagogastroscopy 1.4 ± 0.5 days postablation demonstrated GH and EDELs in 18 (17.3%) and 9 (8.7%) patients. The incidence of GH was similar (7 of 40 vs 11 of 64; P = .967) between the groups, while that of EDELs was significantly higher in the former than in the latter group (8 of 40 vs 1 of 64; P < .0001). In multivariate analyses, the esophagus-right inferior pulmonary vein ostium distance (hazard ratio 0.870; 95% confidence interval 0.798-0.948; P = .002) was the sole predictor of GH, and the optimal cutoff for the prediction was 18.2 mm (sensitivity 88.1%; specificity 77.8%). The use of esophageal probes was the sole predictor of EDELs (hazard ratio 15.750; 95% confidence interval 1.887-131.471; P = .011). All collateral damage was asymptomatic and healed on repeat esophagogastroscopy at a mean of 2 ± 1 months postprocedure.
Second-generation cryoballoon ablation is associated with an increased incidence of silent periesophageal nerve injury even using short freeze times, and anatomical information aids identifying high-risk populations. The use of esophageal probes increases the risk of EDELs.
The post-second-generation cryoballoon (CB) ablation isolation area during the chronic phase has not been described. The aim of this study was to quantitatively evaluate the chronic-phase isolation ...area after 28-mm second-generation CB ablation and compare it to the estimated conventional radiofrequency circumferential pulmonary vein isolation (CPVI) line.
Thirty-two patients with paroxysmal atrial fibrillation underwent pulmonary vein (PV) isolation using second-generation CB. After a median of 6.0 (4.0-9.0) months, the PV isolation area was evaluated using high-resolution mapping (1-mm electrode, 2-mm interelectrode spacing; 527±99 points per map) and pacing techniques in all patients (17 with and 15 without arrhythmia recurrence beyond blanking period) and compared with estimated conventional radiofrequency CPVI area. PV reconnections were observed in 34 of 126 PVs (27.0%) among 21 of 32 patients (65.6%), which were eliminated by a median of 1.0 (1.0-3.0) focal radiofrequency application. The left- and right-sided PV antrum isolation area and nonablated posterior wall areas were 9.8±1.7, 8.1±2.3, and 17.0±6.1 cm(2), respectively. The cryoablated areas were significantly smaller than the estimated conventional radiofrequency CPVI areas in all but the right inferior PV. The difference was highest in the left superior PV. In 2 patients (6.3%), recurrent atrial fibrillation originated from the foci identified at the left superior PV antrum outside the CB isolation area but inside the estimated conventional radiofrequency CPVI line.
Although the PV isolation areas during the chronic phase after the second-generation CB ablation were generally wide, they were significantly smaller than the area encircled by the CPVI line except at the right inferior PV antrum. Recurrent atrial fibrillation could originate from the left superior PV antrum and could be isolated by a CPVI but not by a CB.
•Freedom from composite endpoint at 3-years was high in HFrEF and HFpEF patients.•Smaller LV diastolic diameter was the sole predictor of LVEF normalization.•No recurrence after initial procedure was ...the sole predictor of shortening of the LV diastolic diameter.
Heart failure (HF) promotes atrial fibrillation (AF) and AF worsens HF. This study aimed to investigate the long-term clinical outcomes after AF ablation in patients with HF.
A total of 106 consecutive HF patients, including 51 (48.1%) with a reduced left ventricular ejection fraction (LVEF) (HFrEF) and 55 (51.9%) with a preserved LVEF (HFpEF), underwent AF ablation. All patients underwent successful pulmonary vein antrum isolation, and substrate modification was added in 38 (35.8%). The mean follow-up period was 32.4±18.6 months, and mean number of procedures was 1.4±0.5 per patient. Low-dose antiarrhythmic drugs were combined in 29 (27.3%) patients. Freedom from recurrent atrial arrhythmias (ATa), HF-related hospitalizations, and the composite endpoint (all-cause death, stroke, HF-related hospitalizations) at 3 years was 88.7%, 97.6%, and 97.6% in HFrEF patients, and 79.3%, 96.2%, and 91.8% in HFpEF patients, respectively. LVEF normalization (≥50%) was observed in 37 (72.5%) HFrEF patients post-ablation, and a smaller LV diastolic diameter (LVDd) was the sole predictor odds ratio (OR)=0.863; 95% confidence interval (CI)=0.779–0.955, p=0.005. Shortening of the LVDd (≥5mm) was observed in 16 (29.1%) HFpEF patients post-ablation, and no recurrence after the initial procedure was the sole predictor (OR=6.229; 95% CI=1.524–25.469, p=0.011).
Catheter ablation of AF could be one of the important therapeutic options in the management of patients with HF combined with AF regardless of the type of HF.
Background:Inflammation plays a prominent role in the etiology of the early recurrence of atrial fibrillation (ERAF). We prospectively compared the proportion of ERAF and time-course patterns of ...biomarkers between radiofrequency (RF) and cryoballoon (CB) ablation.Methods and Results:We enrolled 82 consecutive paroxysmal AF patients undergoing pulmonary vein (PV) isolation, performed with either a 28-mm 2nd-generation CB and 3-min freeze technique or point-by-point RF ablation. Each group had 41 patients. In the RF group, all PVs were successfully isolated with 28.9±6.5 min of RF delivery. In the CB group, a mean of 5.3±1.4 applications/patient was delivered. The proportion of ERAF was similar between the groups. The time-course patterns significantly differed between the groups for high-sensitivity C-reactive protein (hs-CRP) value (P=0.006) and myocardial injury markers (P<0.0001). Greater myocardial injury was observed in the CB than in the RF group (P<0.0001), whereas the peak hs-CRP value was comparable between the groups. The 2-day post-procedure hs-CRP value was the sole factor correlating with ERAF as identified by the multivariable analysis (hazard ratio 1.697; 95% confidence interval, 1.005–2.865; P=0.048) in the RF, but not the CB group.Conclusions:The proportion of ERAF was comparable after RF and 2nd-generation CB ablation. Despite CB ablation exhibiting greater myocardial injury than RF ablation, the inflammatory responses were comparable between the groups. The inflammatory response extent predicted ERAF post-RF ablation but not post-CB ablation. (Circ J 2016; 80: 346–353)
Introduction
Beyond pulmonary vein isolation (PVI), additional therapeutic strategies for atrial fibrillation (AF) have not been established. Remodeling of the left atrium (LA) could impact AF ...recurrence post‐PVI. We investigated the impact of unipolar voltage (UV) criteria for the LA posterior wall (LA‐PW) on AF recurrence post‐PVI.
Methods
We reviewed the cases of 106 AF patients (mean age 63.8 years, nonparoxysmal AF: 59%) who underwent extensive encircling PVI by radiofrequency ablation guided by a 3‐dimension mapping system, investigating the impact on AF recurrence of the UV criteria of the LA.
Results
Out of all patients, 26 patients had AF recurrence during post‐PVI follow‐up median 603 days. They showed a higher percentage of nonparoxysmal AF (80.8 vs. 52.5%, p = .011), longer AF duration (2.9 ± 2.7 vs. 1.0 ± 1.7 years, p = .002), and larger area size of UV < 2.0 mV in LA‐PW (2.8 ± 1.8 vs. 1.0 ± 1.5 cm2, p < .001) than those without recurrence. Cox Hazard analysis for AF recurrence adjusted by age, gender, AF duration, body mass index and left atrial volume index revealed that an area size over 2.0 cm2 of UV < 2.0 mV in LA‐PW (HR 6.9 95% CI:1.3–35.5, p = .021) posed independent risks for AF recurrence post‐PVI. The atrial arrhythmia‐free survival rate was higher in those with no area of UV < 3.0 mV in LA‐PW compared to those with a sizable area (>2.0 cm2) of UV < 3.0 mV and <2.0 mV (95.0% vs. 74.2% vs. 57.1%, Log‐Rank: p < .001). In the AF etiology of patients with AF recurrence, 9 of 14 patients who underwent the 2nd procedure had no PV reconnection, and 8 patients required the LA‐PW isolation for their non‐PV AF.
Conclusion
UV criteria of LA‐PW is a useful parameter for AF‐recurrence post‐PVI. Lower UV in LA‐PW as an indication of electrical remodeling could indicate a higher risk of AF recurrence and the need for further therapeutic strategies.
A representative case exhibiting a serial change of LA remodeling. Pre‐voltage mapping at the 1st procedure before PVI showed no low voltage area in bipolar voltage mapping (left upper panel) and a unipolar voltage area of 3.0 cm2 of UV < 2.0 mV in LA‐PW (right upper panel). The patient underwent the only PVI. The patient had recurrence of AF after PVI. Voltage mapping at the 2nd procedure 7 months later indicated no PV reconnection and heterogeneous spread of low voltage area in LA‐PW (left lower panel). Area of UV < 2.0 mV was wider than the bipolar low voltage area of conventional criteria in LA‐PW. LA‐PW isolation for the non‐PV AF foci was needed to maintain sinus rhythm at the 2nd procedure. Patients were divided to three groups based on the voltage criteria in LA‐PW: (A) no area of UV < 3.0 mV, (B) area size over 2.0 cm2 of UV < 3.0 mV, (C) area size over 2.0 cm2 of UV < 2.0 mV. Group (B) did not include group (C): group (B) had the area size over 2.0 cm2 of UV 2.0 mV≤ and <3.0 mV. Kaplan–Meier AF/AT free survival curve indicated that the AF/AT free survival rate of the patients with no area of UV < 3.0 mV in LA‐PW was significantly higher than those with area size over 2.0 cm2 of UV < 3.0 mV or <2.0 mV in LA‐PW (95.0% vs. 74.2% vs. 57.1%, median follow‐up duration of 603 days, Log‐Rank (Mantel–Cox): p < .001). AF, atrial fibrillation; AT, atrial tachycardia; PVI, pulmonary vein isolation; LA, left atrium; PW, posterior wall; UV, unipolar voltage.
Esophagus‐Related Complications After Cryoablation
Background
Monitoring luminal esophageal temperatures (LETs) helps predict esophageal thermal lesions (ETLs) after catheter ablation. This study ...aimed to evaluate esophagus‐related complications after second‐generation cryoballoon ablation under simultaneous LETs monitoring from 2 esophageal probes.
Methods
Forty consecutive paroxysmal atrial fibrillation patients undergoing second‐generation cryoballoon ablation under conscious sedation followed by esophagogastroscopy were prospectively included. Two temperature probes inserted bi‐nasally (both non‐deflectable in 13, non‐deflectable and deflectable in 27 patients) were used for LET monitoring. Pulmonary vein isolation was performed with one 28‐mm balloon using single 3‐minute freeze techniques.
Results
The lowest LETs significantly correlated between different probes; however, deflectable probe showed significantly lower nadir LETs than non‐deflectable probes (14.6 ± 9.2 vs. 20.0 ± 10.6 ℃, P<0.0001). Esophagogastroscopy post‐ablation demonstrated ETLs and gastroparesis in 8 (20%) and 7 (17.5%) patients (total 13 32.5%), respectively. The optimal cutoff for the lowest LET measured on any probe for predicting no ETLs was 12.8 ℃ (sensitivity 78.1%, specificity 100%). When using deflectable and non‐deflectable catheters, the optimal cutoff point for the lowest LET for predicting no ETLs was 11.4 ℃ (sensitivity 70.0%, specificity 100%) and 19.4 ℃ (sensitivity 63.6%, specificity 100%), respectively. No ETLs were detected in 12 (30%) patients with the esophagus located between the left atrium and spine. All esophagus‐related complications were asymptomatic and had healed on repeat esophagogastroscopy by a mean of 53 ± 25 days after the procedure.
Conclusions
The lowest LET highly depended on the temperature probe location. However, if a different cutoff value was applied, LET monitoring, regardless of the probe type, and anatomical information might help predict ETLs during second‐generation cryoballoon ablation.
Background Phrenic nerve injury (PNI) is recognized as an important complication during atrial fibrillation ablation. This study aimed to investigate the incidence and outcome of PNI during superior ...vena cava isolation (SVCI) and circumferential pulmonary vein isolation (CPVI) using radiofrequency (RF) energy and the factors associated with its occurrence. Methods and results Five hundred sixty-seven consecutive patients who underwent SVCI after CPVI without substrate modification who completed a 12-month follow-up were retrospectively analyzed. Point-by-point RF applications were applied with maximum energy settings of 35 W and 30 seconds for the SVCI. In the former 210 patients, sites where pacing captured the PN were avoided whenever possible; however, the maximum power was 35 W. In the latter 357 patients, RF energy was delivered regardless of PN capture; however, the power at PN capture sites was limited to 10 W during continuous diaphragmatic movement monitoring on fluoroscopy. Circumferential pulmonary vein isolation and SVCI were successfully achieved in all. Twelve patients (2.1%) had PNI during SVCI but not during CPVI. Phrenic nerve injury completely recovered in all patients a median of 8.0 months after the procedure. The prevalence was higher in the former period (3.8% vs 1.1%; P = .03). A multivariate logistic regression analysis revealed that the study period (odds ratio 3.546; 95% CI 1.051-11.965; P = .041) was the sole independent predictor for identifying patients with PNI during SVCI. Conclusions Phrenic nerve injury occurred in 2.1% of the patients. All occurred during SVCI but not during contemporary CPVI. Energy titration and continuous diaphragmatic movement monitoring significantly decreased the incidence during SVCI.
Radiofrequency applications around pulmonary vein (PV) ostia often induce vagal reflexes.
This study aimed to evaluate the impact of the order of the targeted PV on the vagal response during ...second-generation cryoballoon ablation.
Eighty-one consecutive paroxysmal atrial fibrillation (AF) patients undergoing cryoballoon ablation were prospectively enrolled. PV isolation was performed with one 28-mm second-generation balloon using a 3-minute freeze technique. In the first 39 patients, the left superior PV (LSPV) was initially targeted. In the second 42, the LSPV was targeted following the right PVs.
Baseline rhythms were sinus rhythm and AF in 34 and 5 patients in the first group, and 34 and 8 in the second group, respectively. In the first group, sinus bradycardia/arrest requiring back-up pacing occurred in 13 patients (38.2%) at a median of 41.0 (10.0-55.5) seconds after balloon deflation (90 60-100 seconds post freezing), and pauses requiring pacing in 1 (20.0%) with AF. In the second group, no sinus bradycardia/arrest occurred throughout the procedure; however, atrioventricular block requiring back-up pacing occurred 21 seconds after balloon deflation in 1 patient in whom right superior PV (RSPV) ablation was performed for only 60 seconds owing to right phrenic nerve injury. The cycle length was similar at baseline and post PV isolation between the 2 groups, and significantly shorter during RSPV ablation (P < .0001) in both. In total, marked vagal responses were significantly higher in the first than second group (14/39 vs 1/42, P < .0001).
LSPV cryoballoon ablation often provoked marked vagal responses; however, preceding RSPV ablation markedly suppressed this response.
PDF
