Cryoablation for persistent and longstanding persistent atrial fibrillation: results from a multicentre European registry

Abstract

Aims Although cryoballoon pulmonary vein isolation is a well-established treatment for paroxysmal atrial fibrillation (AF), it’s role in persistent AF is unclear. We examined procedural success and long-term outcomes of cryoablation in persistent and longstanding persistent AF. Methods and results International multicentre registry from three UK and eight European centres. Consecutive patients undergoing cryoablation for persistent AF included. Procedural data, complications, and follow-up were prospectively recorded. Patients were followed-up at 3, 6, and 12 months with an electrocardiogram with open access to arrhythmia nurses thereafter. Ambulatory monitoring was dictated by symptoms. Success was defined as freedom from AF or atrial tachycardia lasting >30 s off antiarrhythmic drugs (AADs). Six hundred and nine consecutive cryoablation procedures. Mean procedure and fluoroscopy times were 95 ± 65 and 13 ± 10 min. Single procedure success rates were 368/602 (61%) off AADs over a median of 2.4 (1.0–4.0) years. Arrhythmia-free survival off AADs was 64% and 57% for persistent and longstanding persistent AF at 24 months of follow-up (P = 0.02). Rate of repeat ablations was 20% in persistent and 32% in longstanding persistent AF (P = 0.006). Cox regression analyses showed a significant association between duration of AF and left atrial diameter and arrhythmia recurrence [hazard ratio (HR) 1.05, P-value 0.01 and HR 1.02, P-value 0.004]. Conclusion Cryoablation for persistent AF is safe, fast and has good outcomes at long-term follow-up. Cryoablation is reasonable as a first line option for these patients. Short procedure times may help increase capacity of cardiac units to meet the rising demand for AF ablation. Randomised control trials are needed to compare outcomes with different techniques.

Strategies to Improve the Outcome of Cryoballoon Ablation in the Treatment of Atrial Fibrillation

“…A single-center large-scale study also found that the free survival rate for atrial arrhythmias was 78.6% after a single procedure for PaAF and 72.3% for PeAF at a median 39 months follow-up [9]. CBA treatment also achieved a similar success rate without obvious complications compared to RFCA both in elderly AF patients (>75 years old) and patients with PeAF and longstanding PeAF [10,11]. Collectively, CBA has become one of the main pillars and is recommended as the first-line therapy in the management of patients with AF [12,13].…”

Intraprocedural Conversion Efficacy of Intravenous Nifekalant Administration for Persistent Atrial Fibrillation after Pulmonary Vein Isolation

“…In our study, the 1-year ATafree survival rate is similar to previously published data achieved using a CB in PerAF patients, whereas Straube reported a 1-year ATa-free survival rate of 82%. 3,15) CBA as an index procedure for PerAF: To date, PVI is the cornerstone of ablation for AF and represents the first step in AF ablation, and CBA has demonstrated satisfactory acute and mid-term clinical results by achieving PVI in nearly all PVs approached, with a very low incidence of acute reconnection. 16,17) However, the role of additional line ablation and CFAE ablation at the time of the index procedure is still controversial and poorly standardized.…”

“…1) Related studies have demonstrated the ablation efficacy of PVI as an index procedure using a cryoballoon (CB) for patients with paroxysmal AF (ParAF) and persistent AF (PerAF). [2][3][4] For PerAF patients, in addition to PVI, other targets for radiofrequency catheter ablation (RFCA) have included complex fractionated atrial electrograms (CFAEs), empiric additional line ablation, and driving rotors, with reported 1-year efficacy rates of 29%-60%. [5][6][7][8] Recent data have brought into question the utility and safety of the aforementioned RFCA strategies other than PVI, which may lead to an increased incidence of RFCA-related atrial flutter (AFL), pericardial effusion, and other complications.…”

Freezing left atrial scar: The new Ice Age?

“…Furthermore, the FIRE AND ICE study, the largest randomized trial comparing CB versus radiofrequency (RF) energy for PVI in paroxysmal AF patients, reported approximately 68% freedom from the primary efficacy end point with CB ablation (per‐protocol analysis) and established non‐inferiority of CB ablation to RF ablation 4 . CB‐based PVI has also been shown to be effective in persistent AF patients, with success rates of 61% at 12 months after a single procedure 5,6 …”

“…4 CB-based PVI has also been shown to be effective in persistent AF patients, with success rates of 61% at 12 months after a single procedure. 5,6 In addition to PVI, substrate modification at the time of first ablation, consisting of complex fractionated electrogram ablation and linear ablation lines, was examined in the STAR AF II and CHASE-AF trials, and did not result in further reduction of AF recurrence relative to PVI alone, though these studies included only persistent AF patients receiving RF ablation. 7,8 Thus, the role of ablation lesions beyond PVI for index ablation, both in paroxysmal and persistent AF, remains a matter of controversy.…”