Durability of cryoballoon left atrial appendage isolation: Acute and invasive remapping electrophysiological findings

Abstract

Background The left atrial appendage (LAA) has been identified as a potential source of atrial fibrillation (AF) and has been described as the “fifth” pulmonary vein (PV). We report our initial experience in LAA isolation (LAAI) using the cryoballoon (CB) and data on durability of CB‐LAAI. Methods Patients treated with a CB‐LAAI were retrospectively identified. Six weeks after electrical LAAI, patients were scheduled for staged percutaneous LAA closure. During the second procedure, a subset of patients underwent invasive remapping of the LAA. Results A total of 32 patients (21 males, 68 ± 10 years old) were treated with CB‐LAAI. Acute LAAI was achieved in 29 of 32 (91%) patients: single‐shot LAAI was observed in 18 of 32 (56%) patients. Acute procedural sustained LAAI was related with a significantly shorter time to LAAI (sustained LAAI: 84 ± 50 s vs nonsustained LAAI: 166 ± 76 s, P = 0.004). Mean procedure and fluoroscopy time were 61 ± 29 and 8 ± 6 min, respectively. One left‐sided phrenic nerve palsy occurred. In 25 of 32 (78%) patients, a second procedure for percutaneous LAA closure device implantation was performed. In 22 patients, persistency of LAAI was tested: durable LAAI was documented in 16/22 patients (73%). Conclusion In the present report, CB LAA isolation followed by staged LAA closure appeared to be safe and feasible but more data are required. Time to LAAI played a role in predicting acute sustained LAAI rate. CB LAA ablation leads to 73% of durable LAA isolation.

Left atrial appendage electrical isolation for persistent atrial fibrillation: Radiofrequency vs cryoballoon ablation

“…However, no RCT has shown that LAA closure devices are superior to uninterrupted OAC in preventing thromboembolism after LAAEI and and no data on thromboembolic complication at long‐term follow‐up are available. Albeit, Bordignon et al suggest that when LAAEI is attempted, a CB approach rather than point‐by‐point RFA around the LAA should be considered, we believe that RFA indeed may be a safer strategy since to date no coronary vessel damage and no LPN paralysis have been reported using this ablation modality . Needless to say, RFA can currently be performed without fluoroscopy or contrast agents in a timely fashion.…”

“…We consider that it is worth assessing for LAA dormant conduction using adenosine or isoproterenol and reassess reconnection after a 30 min waiting period. In this series by Bordignon et al, another great concept arise: LAA occlusion only after confirmation of LAAEI with mapping catheter . More data are needed and larger trials are necessary to support this concept.…”

“…The FIRE and ICE RCT determined that CB ablation is noninferior to radiofrequency (RF) ablation (RFA) in patients with paroxysmal AF. Though the feasibility of CB for non‐PV sites is limited, the studies published by Yorgun et al and now by Bordignon et al, in this issue, clearly demonstrated that this technology might have a larger role in treating patients with nonparoxysmal AF. The authors should be applauded for this outstanding study, particularly for taking the time and use of resources to remap the LAA.…”

“…This was a small, not‐controlled retrospective study, in which patients treated with a CB‐LAAEI were scheduled for staged percutaneous LAA closure (LAAC) 6 weeks later. During the second procedure, a subset of patients underwent invasive remapping of the LAA . One left‐sided phrenic nerve palsy occurred.…”

“…Persistency of LAAEI was tested and durable LAAEI was documented in 73% of cases. These results are novel and clinically relevant due primarily to the fact that the authors have mainly focused on determining the durability of LAAEI with CB …”