Previous studies reported the association between inflammation and atrial fibrillation (AF). Pericoronary adipose tissue (PCAT) attenuation, PCATA, on cardiac CT angiography (CTA) reflects ...pericoronary inflammation. We hypothesized that the PCATA predicts AF recurrence after cryoballoon ablation (CBA) for paroxysmal and persistent AF.
We studied 364 patients (median age, 65 years) with persistent (
= 41) and paroxysmal (
= 323) AF undergoing successful first-session second-generation CBA with pre-ablation cardiac CTA. Three-vessel (3V)-PCATA was defined as the mean CT attenuation value of PCAT of all three major coronary arteries. Predictors of AF recurrence during follow-up were evaluated.
AF recurrence after the 3-month blanking period was detected in 90 patients (24.7%) during the median follow-up of 26 (interquartile range, 19-42) months. AF recurrence was associated with prior stroke and statin use, NT-proBNP and high-sensitivity cardiac troponin-I levels, left ventricular dimension, left atrial volume index (LAVI), 3V-PCATA, and early AF recurrence during the blanking period. On multivariable Cox proportional hazard analysis, prior stroke (hazard ratio HR, 2.208, 95% confidence interval CI, 1.166-4.180,
= 0.015), LAVI (HR, 1.030, 95% CI, 1.010-1.051,
= 0.003), 3V-PCATA (HR, 1.034, 95% CI, 1.001-1.069,
= 0.046), and early AF recurrence (HR, 2.858, 95% CI, 1.855-4.405,
< 0.001) remained statistically significant.
Pre-ablation CTA-derived 3V-PCATA, representing pericoronary inflammation, was an independent predictor of recurrence after first-session AF ablation using a second-generation cryoballoon.
Assessment of 3V-PCATA may identify patients at high risk of AF recurrence after CBA for AF.
A 53‐year‐old male underwent a pulmonary vein isolation (PVI) of atrial fibrillation (AF) with a second‐generation cryoballoon (CB). Although the patient maintained sinus rhythm after the PVI, a ...superior vena cava (SVC) fibrillation was recorded by a circular‐multipolar‐electrode catheter positioned inside the SVC that suggested conduction block between the right atrium (RA)‐SVC connection. An adenosine triphosphate intravenous injection induced a dormant reconnection of the SVC myocardial sleeve and converted sinus rhythm to an AF rhythm. This case demonstrated that a CB application for the isolation of a right superior pulmonary vein could induce an electrical conduction block between the RA‐SVC connection.
The superior vena cava (SVC) is an important focus of atrial fibrillation (AF) for which SVC isolation is effective. However, SVC isolation may cause serious complications, and indications for SVC ...isolation combined with pulmonary vein (PV) isolation are unclear.
The purpose of this study was to identify structural and electrophysiologic differences that might exist between the SVC of patients with and those without SVC triggering of AF.
This study included paroxysmal (n = 46) and persistent (n = 14) AF patients without structural heart disease who underwent circumferential antral PV isolation. Patients with AF of SVC origin were assigned to the SVC group (n = 12); the remaining patients were assigned to the control group (n = 48). The area where SVC potentials were recorded was defined as the SVC sleeve. The length of the SVC sleeve and the maximum amplitude of the SVC potential were measured.
SVC group patients had a longer SVC sleeve (34.7 +/- 4.4 mm vs 16.5 +/- 11.4 mm, P <.0001) than did control group patients. Maximum amplitude of the SVC potential was greater in SVC group patients than in control group patients (1.50 +/- 0.43 mV vs 0.98 +/- 0.60 mV, P = .03). SVC sleeve length >30 mm and maximum amplitude of SVC potential >1.0 mV strongly predicted an SVC focus of AF (100% sensitivity, 94% specificity). Fifty of 60 patients became AF-free without antiarrhythmic drugs after undergoing circumferential antral PV isolation and/or SVC isolation.
The results of this study suggest that in patients with long SVC sleeve (>30 mm) and large SVC potential (>1.0 mV), arrhythmogenic triggers of AF reside in the SVC.
Background
The intrinsic cardiac autonomic nervous system (ANS) plays a significant role in atrial fibrillation (AF) mechanisms. This study evaluated the incidence and impact of intraprocedural vagal ...reactions and ANS modulation by pulmonary vein isolation (PVI) using second‐generation cryoballoons on outcomes.
Methods
One hundred three paroxysmal AF patients underwent PVI with one 28‐mm second‐generation balloon. The median follow‐up was 15.0 (12.0–18.0) months. ANS modulation was defined as a >20% cycle length decrease on 3‐minute resting electrocardiograms at 1, 3, 6, and 12 months postindex procedure relative to baseline if sinus rhythm was maintained.
Results
Marked sinus arrests/bradycardia and atrioventricular block (intraprocedural vagal reaction) occurred in 14 and 2 patients, and all sinus arrest/bradycardia occurred in 44 patients with left superior pulmonary veins (PVs) targeted before right PVs. ANS modulation was identified in 66 of 95 (69.5%) patients, and it persisted 12‐month postprocedure in 36 (37.9%) patients. Additional β‐blocker administration was required in 9 patients for sinus tachycardia. ANS modulation was similarly observed in patients with and without intraprocedural vagal reactions (P = 0.443). Forty‐eight (46.6%) patients experienced early recurrences, and the single procedure success at 12 months was 72.7%. Neither intraprocedural vagal reactions nor ANS modulation predicted AF freedom within or after the blanking period. Thirty‐three patients underwent second procedures, and reconnections were detected in 39 of 130 (30.0%) PVs among 23 (69.7%) patients. The incidence of reconnections was similar in patients with and without ANS modulation.
Conclusions
Increased heart rate persisted in 37.9% of patients even at 12‐month post‐second‐generation cryoballoon PVI. Neither intraprocedural vagal reactions nor increased heart rate predicted a single procedure clinical outcome.
In patients with paroxysmal atrial fibrillation (PAF), 10%-15% of patients require repeat procedures after second-generation cryoballoon pulmonary vein isolation (CB-PVI). We sought to explore the ...mechanisms of recurrences after cryoballoon ablation.
The data of 122 PAF patients who underwent second procedures for recurrent arrhythmias 7.0 (4.0-12.0) months after the CB-PVI were analyzed. During second procedures, non-PV AF foci were explored with isoproterenol, adenosine, and repetitive cardioversions.
In total, 378/487 (77.6%) PVs remained isolated, and reconnections were not observed in any PVs in 59 (48.4%) patients. PV reconnections were associated with recurrences in 38 (31.1%) patients, of whom 33 (86.8%) had reconnections of at least 1 upper PV. In 6 (4.9%) patients, non-PV AF foci were identified in the upper PV antra where cryoballoons cannot isolate but within the circumferential radiofrequency PVI line. Non-PV AF foci were identified in the superior vena cava, right atrial body, left atrial body, and atrial septum in 28 (23.0%), 18 (14.7%), 4 (3.3%), and 5 (4.1%) patients, respectively. Twelve (9.8%) patients had multiple non-PV AF foci. Four (3.3%), 3 (2.4%), and 8 (6.5%) patients underwent second procedures for atrioventricular nodal reentrant tachycardia, atrial flutter, and atrial tachycardias. During 16.0 (8.0-24.0) months of follow-up, freedom from any atrial arrhythmia at 1 year and 2 years after the second procedure was 79.2% and 60.6%. Nineteen (15.5%) patients had antiarrhythmic drug therapy at the last follow-up.
Our study suggested that improvement in the upper PV PVI durability, eliminating arrhythmogenic superior vena cavae and coexisting atrial arrhythmias, and bonus cryoballoon applications at PV antra might improve the single procedure outcome in cryoballoon ablation.
Background:Early recurrence of atrial fibrillation (ERAF) is common after pulmonary vein antrum isolation (PVAI); however, the definition, study population, and lesion set are not uniform in prior ...studies. We examined ERAF for paroxysmal AF while complying with the definition in the latest guidelines.Methods and Results:We included 471 patients undergoing empirical PVAI for paroxysmal AF. ERAF was observed in 180 patients (38.2%) including 49, 16, and 115 within 3, 4–7 days, and 8–90 days, respectively, after the index procedure. ERAF (hazard ratio 6.872; 95% confidence interval 4.803–9.382; P<0.0001) was the strongest factor associated with recurrence beyond 3 months (LR) in the multivariable model, and ERAF patients had worse outcomes than those without, regardless of the time to the first ERAF episode. There were no significant differences in the prevalence of PV reconnections and non-PV foci among 29 and 62 patients, respectively, who underwent redo procedures for ERAF within and more than 3 months after the index procedure, and 21 who underwent redo procedures for LR. Re-ablation was associated with a greater freedom from LR (HR 0.443; 95% CI 0.230–0.854; P=0.015).Conclusions:ERAF occurred in 38.2% of patients and was strongly associated with LR regardless of the time to the first ERAF episode. Re-ablation for ERAF significantly improved the freedom from recurrent atrial arrhythmias, regardless of the time to the first ERAF episode. (Circ J 2015; 79: 2353–2359)
Background
Electrical connections between ipsilateral pulmonary veins (PVs) have been reported histologically and electrophysiologically. This study investigated the impact of electrical connections ...between ipsilateral PVs on PV isolation using second‐generation cryoballoons (CB2‐PVI).
Methods
Five hundred eleven atrial fibrillation patients, without any PV anomalies, underwent CB2‐PVI using one 28‐mm balloon and a single 3‐minute freeze strategy without any bonus applications.
Results
Overall, 1966 of 2044 (96.2%) PVs were isolated exclusively by using 28‐mm cryoballoons. Among them, 13 left superior PV (LSPVs) and two right superior PV were not persistently isolated by the first application despite a complete vein occlusion, but were isolated by subsequent applications targeting other ipsilateral PVs. Among the 13 LSPVs, six were transiently isolated by 87 (62‐146) second time‐to‐isolation LSPV applications, but were immediately reconnected after the application. The nadir balloon temperature during the LSPV application was similar between the 13 LSPVs not isolated by the LSPV application but were not so by subsequent left inferior PV (LIPV) applications and the 488 LSPVs persistently isolated by LSPV applications (−49.4℃ ± 4.3℃ vs −50.8℃ ± 5.1℃; P = 0.328). In 59 patients in whom the initial LSPV application failed despite a complete occlusion, LIPVs were targeted for the second applications in 31 patients, and both the LSPV and LIPV were simultaneously isolated in 13 of 31 (41.9%).
Conclusions
Electrical connections between ipsilateral PVs could have an impact on the CB2‐PVI procedure. When the vein isolation failed despite a complete occlusion, especially for left ipsilateral PVs, it was reasonable to target the other ipsilateral PV instead of repeatedly targeting the same vein.
Early recurrence (ER) of atrial fibrillation (AF) is common after ablation of longstanding persistent AF. However, optimal timing for repeat ablation has yet to be established.Two-hundred-four ...patients (mean age 62 ± 9 years) with longstanding persistent AF underwent catheter ablation including pulmonary vein (PV) isolation and substrate modification. ER defined as AF recurrence within 60 days, occurred in 115 patients (56.4%) 9 ± 1 days after the procedure. Analysis showed optimal blanking period to be 15 days. At 426 ± 224 days of follow-up, 30 of 50 (60.0%) patients with ER during the first 15 days (ER ≤ 15) and 13 of 65 (20.0%) patients with ER from the 16th to the 60th day (ER16-60) were free from protocol-defined treatment failure (PDTF) (P < 0.0001). In multivariate analysis, AF duration and LA diameter were independent predictors of ER16-60. Peak first ER was in the first 5 days, with a small maximum in the day 15~20 bin. The mean time to the first ER was longer in patients found to have PV reconnection during the repeat ablation than in those without (13 ± 14 versus 6 ± 7 days, P = 0.002).When adopting a blanking period of 15 days, fewer patients with an ER ≤ 15 had PDTF than those with an ER16-60. AF duration and LA diameter were predictive of an ER16-60.
Electrical reconnections after pulmonary vein isolation (PVI) are less common after second-generation cryoballoon than radiofrequency ablation.
The purpose of this study was to investigate the ...incidence and characteristics of pulmonary vein (PV) reconnections after second-generation cryoballoon ablation in patients with and those without clinical recurrences.
Forty patients with paroxysmal atrial fibrillation undergoing second procedures after cryoballoon ablation were enrolled. Twenty-five patients experienced clinical recurrences, and the remaining 15 did not.
All 158 PVs were reevaluated a median 25th, 75th percentiles of 6.0 4.0-9.0 months after the initial procedure. In total, reconnections were detected in 39 PVs (24.7%) among 25 patients (62.5%). Reconnected PVs included 6 left superior (LS) (15.8%), 7 left inferior (LI) (18.4%), 5 right superior (RS) (12.5%), 20 right inferior (RI) (50.0%), and 1 left common (LC) (50.0%) PV. Reconnected PV potential conduction delays were a median of 112 76-130, 103 82-133, 84 66-96, 68 49-73, and 204 ms in the LS, LI, RS, RI, and LC PV, respectively. There was no significant difference between those with and those without clinical recurrences with regard to clinical characteristics, procedural results, incidence of reconnections (25/98 vs 14/60, P = .758), and PV conduction delays in each PV. The most common gap location was the RI PV bottom in both groups. Among 5 patients with reconnections of arrhythmogenic PVs (with atrial fibrillation initiation), 2 experienced clinical recurrences, whereas 3 did not. Non-PV foci (with atrial fibrillation initiation) were identified in a second procedures in 10 of 25 patients with clinical recurrences.
The incidence and characteristics of PV reconnections after second-generation cryoballoon ablation were similar between patients with and those without clinical recurrences. The results should be considered when discussing the optimal dose of cryoballoon applications.
Few data are available regarding pulmonary vein (PV) stenosis after second-generation cryoballoon PV isolation (CB2-PVI). Currently, a single short freeze strategy is standard for CB2-PVI owing to ...enhanced cooling effects. This study aimed to evaluate the incidence of PV stenosis after CB2-PVI with the current standard strategy.
Two hundred seventy-six atrial fibrillation patients underwent CB2-PVI using one 28-mm balloon and single 3-minute freeze strategy. If balloon temperatures reached −60 °C or phrenic nerve injury was suspected, freezing was terminated. Enhanced cardiac computed tomography (CT) was obtained before and >3 months after the procedure.
Overall, 1067 of 1101 (96.9%) PVs were isolated with cryoballoons, while the remaining 34 PVs required touch-up ablation. The total application number/patient was 5.1 ± 1.4, and total application time 216 ± 104, 205 ± 77, 186 ± 68, and 246 ± 142 s for the left superior (LSPV), left inferior (LIPV), right superior (RSPV), and right inferior PVs, respectively. Follow-up CT obtained a median of 5.0 3.3–7.0 months post-procedure revealed no PVs with moderate or severe stenosis. Asymptomatic mild stenosis was documented in 16 total (1.4%) PVs (5 LSPVs, 5 LIPVs, and 6 RSPVs), but not in right inferior, left common, right middle, or PVs requiring touch-up ablation. Mild stenosis did not progress during the follow-up. Among the potential factors associated with PV stenosis, longer application times were the sole significant factor associated with mild RSPV stenosis.
In CB2-PVI with the current single short freeze strategy, the risk of PV stenosis is extremely low, and routine follow-up imaging for evaluation seems not to be necessary.
•In current second-generation CB ablation strategy, none of the PVs exhibited moderate or severe PV stenosis.•Asymptomatic mild PV stenosis was detected in 1.4% of the PVs, but not in the RIPV, LCPV, or right middle vein.•None of the mild PV stenosis progressed during the follow-up period.•A longer application time was the sole significant factor associated with the incidence of mild RSPV stenosis.
PDF
