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Introduction: The left atrial (LA) posterior wall (LAPW) has been targeted to improve the clinical outcomes in patients with persistent atrial fibrillation (PersAF). This study aimed to investigate the feasibility, safety, and clinical implications of cryoballoon (CB) applications on the LAPW to accomplish electrical isolation (EI) of the LAPW with CB.Methods: A total of 100 patients (males, 84; mean age, 64 ± 10 years) with PersAF were enrolled. The first 50 patients underwent only pulmonary vein isolation (PVI) (PVI-only group) and the remaining 50 patients underwent PVI and EI of the LAPW with CB (EI-LAPW group). Results:One-year sinus rhythm maintenance probability was significantly higher in the EI-LAPW group than in PVI-only group (80.0% vs 55.1%, P = 0.01). The success rate of constructing an LA roof block line (LA-RB), bottom block line, and EI of the LAPW was 92%, 60%, and 58%, respectively. The nadir CB temperature (−45°C ± 4°C vs −39°C ± 5°C, P = 0.005) and anatomical angle of the left atrial roof (106°C ± 30°C vs 144°C ± 17°C, P < 0.001) significantly predicted the successful LA-RB construction.The left ventricular ejection fraction was significantly higher in unsuccessful cases than in successful cases of an EI of the LAPW (64% ± 8% vs 58% ± 11%, P = 0.041).Even though the EI of the LAPW was unsuccessful, CB freezing in LAPW significantly debulked the nonscar area (≥0.1 mV) in LAPW (18.1 ± 5.6 vs 2.2 ± 3.1 cm 2 , P < 0.001) and provided the equivalent 1-year outcome of successful cases (79.3% vs 81.0%, P = 0.90). Conclusion:The combination of PVI and EI of the LAPW with CB provided better clinical outcomes than conventional PVI procedure for patients with PersAF. K E Y W O R D S atrial fibrillation, cryoballoon, electrical isolation of left atrial posterior wall J Cardiovasc Electrophysiol. 2019;30:805-814.wileyonlinelibrary.com/journal/jce

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Background: Catheter manipulation in the left-sided heart is known as a risk for cerebral embolisms (CEs). However, anticoagulation therapy is terminated before catheter ablation (CA) of atrial fibrillation (AF) concerning adverse bleeding events. Little is known whether uninterrupted direct oral anticoagulants (DOACs) during perioperative period of CA could render the ablation procedure safer and reduce the incidence of CEs compared to interrupted DOACs. The aim of this study was to investigate the safety and usefulness of uninterrupted dabigatran during the periprocedural period for CA of AF. Methods: We included 333 patients with paroxysmal AF undergoing cryoballoon CA (CBA). They were prospectively divided into 2 groups based on whether DOACs were interrupted on the day of the CA (Group A, n = 228) or dabigatran was not interrupted throughout perioperative period (Group B, n = 105) in a non-randomized fashion. When the Group B patients had taken other DOACs rather than dabigatran before assignment, we changed those DOACs to dabigatran. Brain magnetic resonance imaging (MRI) was undertaken on the following day of the CA. Serious bleeding event cases were excluded from the study. Results: The baseline characteristics including the CHADs2 score did not exhibit any significant differences between the groups. The brain MRI revealed an acute CEs in 82 patients, and was significantly higher in Group A than B (29% vs. 13%, respectively, p < 0.01). There were no significant differences regarding the bleeding events (7% vs. 4%, respectively, p = 0.62). Conclusion: Uninterrupted dabigatran therapy during the CBA of paroxysmal AF could significantly reduce the incidence of CEs.

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