Cryoballoon ablation of atrial fibrillation: a practical and effective approach

Abstract

Medical management of atrial fibrillation (AF), the most common arrhythmia in the general population, has had modest efficacy in controlling symptoms and restoring and maintaining sinus rhythm. Since the seminal observation in 1998 that pulmonary veins host the triggers of AF in the majority of cases, electrical isolation of all pulmonary veins constitutes the cornerstone of ablation in patients with symptomatic AF. However, due to the elaborate and tedious technique of the conventional point-by-point method with radiofrequency ablation guided by electroanatomical mapping, newer, more versatile single-shot techniques, such as cryoballoon ablation, have been sought and developed over recent years and are progressively prevailing.Cryoballoon ablation appears to be the most promising practical and effective approach, and we review it here by presenting all available relevant data from the literature as well as from our own experience in an attempt to apprise colleagues of the significant progress made over the last several years in this important field of electrophysiology. K E Y W O R D Satrial fibrillation, catheter ablation, radiofrequency, cryoballoon, cryoablation, pulmonary vein isolation 1 | INTRODUCTION Atrial fibrillation (AF) is the most common cardiac arrhythmia, afflicting 1% to 2% of the general population, with an age-dependent incidence reaching~10% in individuals age >80 years. In the United States, its prevalence was estimated to range from~2.7 million to 6.1 million in 2010, predicted to rise to 12.1 million in 2030. 1 In the European Union, the prevalence of AF in adults age >55 years was estimated to be 8.8 million in 2010, projected to rise to 17.9 million in 2060. 2 AF increases morbidity, mainly related to stroke and heart failure (HF), as well as overall mortality. It is therefore clear that it constitutes a growing major public-health burden, with considerable socioeconomic impact. As medical management has had modest efficacy in controlling this arrhythmia, over the last several years hope has been rekindled with the advent of more-effective ablation techniques.Since the seminal observation of pulmonary-vein triggers in AF, 3 there has been a significant increase in the number of AF patients submitted to pulmonary vein (PV) isolation (PVI), which constitutes the cornerstone of ablation in patients with symptomatic, drugrefractory AF. 4,5 However, due to the elaborate and tedious technique of the initial point-by-point method with radiofrequency (RF) ablation guided by electroanatomical mapping, penetration of this conventional approach was slow. Most recently, the advent of single-shot techniques, such as cryoballoon ablation, has ushered in a new era in the management of AF patients. 6,7 | AF MECHANISMSDespite the significant progress made in understanding the complex pathophysiology of AF, the precise mechanisms underlying its onset and persistence remain elusive. In brief, AF requires both a trigger and a susceptible substrate. 8 The trigger for initiation and maintenance of AF seem...

Meta‐analysis of randomized controlled trials on atrial fibrillation ablation in patients with heart failure with reduced ejection fraction

“…CA is a well‐established therapy for patients with AF refractory to antiarrhythmic drugs . This meta‐analysis addresses the rapidly evolving role of CA in patients with AF and HFrEF .…”

“…CA is a well-established therapy for patients with AF refractory to antiarrhythmic drugs. 22,23 This meta-analysis addresses the rapidly evolving role of CA in patients with AF and HFrEF. 24 Traditionally, CA in patients with AF and HFrEF has been deemed less desirable due to a potential lower success rate and higher procedural complications.…”

Ablation of atrial fibrillation: single-shot techniques poised to dominate rhythm control strategies/the future is here

“…Two recently developed technologies provide the singleshot approach to PVI, the multi-electrode circular ablation catheter and the cryoballoon catheter (5)(6)(7)(8)(9). Both these methods have emerged as valid alternatives to point-bypoint RF ablation with the added advantage of combining mapping and PVI in a single-shot and shorter procedure.…”

“…Over the recent years, the advent of single-shot techniques has ushered in a new era in the AF ablation approach and rhythm control strategies (5,6). These techniques make it easier to navigate the heart and have the potential to decrease the threshold for and expand the access to rhythm-control therapies, that may furnish further reduction of the AF disease burden.…”

Management of anticoagulation in rate controlled atrial fibrillation: A three-step approach

“…This method is of highest utility if it is used early in disease progression (9). Radiofrequency ablation and cryoablation, additional forms of rhythm control, are best suited for young individuals without structural heart disease or for those who are intolerant to or refractory to antiarrhythmic medications (10,11).…”