Pulmonary vein isolation in patients with paroxysmal atrial fibrillation
Abstract: Second-generation CB provided significantly better clinical outcomes than its predecessor and was associated with low peri- and postprocedural complications.
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Cited by 4 publications
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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...
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...
Atrial fibrillation (AF) affects 1-2% of the population, and its prevalence is estimated to double in the next 50 years as the population ages. AF results in impaired patients' life quality, deteriorated cardiac function, and even increased mortality. Antiarrhythmic drugs frequently fail to restore sinus rhythm. Catheter ablation is a valuable treatment approach for AF, even as a first-line therapy strategy in selected patients. Effective electrical pulmonary vein isolation (PVI) is the cornerstone of all AF ablation strategies. Use of radiofrequency (RF) catheter in combination of a three-dimensional electroanatomical mapping system is the most established ablation approach. However, catheter ablation of AF is challenging even sometimes for experienced operators. To facilitate catheter ablation of AF without compromising the durability of the pulmonary vein isolation, "single shot" ablation devices have been developed; of them, cryoballoon ablation, is by far the most widely investigated. In this report, we review the current knowledge of AF and discuss the recent evidence in catheter ablation of AF, particularly cryoballoon ablation. Moreover, we review relevant data from the literature as well as our own experience and summarize the key procedural practical techniques in PVI using cryoballoon technology, aiming to shorten the learning curve of the ablation technique and to contribute further to reduction of the disease burden.
Background: The Arctic Front Advance System with nitrous oxide (N 2 O) refrigerant is the leading system for the cryoballoon ablation of atrial fibrillation (AF). A novel cryoablation system with nitrogen (N 2 ) refrigerant was developed with technical improvements seeking to improve outcomes. Cryoballoon ablation with the N 2 refrigerant may be effective and safe for pulmonary vein isolation (PVI).Methods: In total, 16 dogs were included in the study, of which 13 underwent PVI procedures, and 3 served as baseline controls. Cryoballoons (Cryofocus, Int.) with N 2 refrigerant were used for the study group, which comprised 8 dogs, and second-generation cryoballoons with N 2 O refrigerant (Arctic Front Advance; Medtronic, Inc., MN, USA) were used for the control group, which comprised 5 dogs. Three dogs of the study group and 2 dogs of the control group were euthanized on the same day post-ablation. The other 8 dogs of the two groups were euthanized 1 month post-ablation. The removed organs were examined for gross anatomy and histological review. Results:The average ablation times for each pulmonary vein (PV) in the study group were less than those in the control group (1.1±0.3 vs. 2.0±0.8; P=0.006). The procedure duration of the study group was shorter than that of the control group (379±46 vs. 592±162 s; P=0.013). And the time to isolation (TTI) was similar between the groups. The PVI rate of the single-ablation was higher in the study group than the control group (92.9% vs. 60.0%; P=0.05). In relation to safety, there was no evidence of thrombus, esophageal injury, or pericardial tamponade in any of the dogs. Only 1 incidence of self-limited phrenic nerve paralysis (PNP) was observed in the control group.Conclusions: The novel cryoablation system with the N 2 refrigerant had better efficacy than and similar safety to that of the system (Medtronic, Int.) with the N 2 O refrigerant.
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