Rationale and Outcomes of Cryoballoon Ablation of the Left Atrial Posterior Wall in Conjunction with Pulmonary Vein Isolation

Aryana, Arash

doi:10.19102/icrm.2021.120801

Cited by 5 publications

(6 citation statements)

References 79 publications

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“…Pulmonary vein isolation alone may be insufficient for treatment of patients with persistent AF. The posterior left atrial region encompassed by the LA roof, superiorly, the left and the right PVs, laterally, and the plane extending from the lower borders of the left and the right inferior PVs, form the PV component of the left atrial posterior wall, which has been implicated in genesis and maintenance of persistent AF (302). Surgical literature has suggested that isolating the "box" between the PVs in the left atrial posterior wall (LAPW) is associated with improved AF outcomes (302).…”

Section: Evolving Concepts In Catheter Ablation Of Afmentioning

confidence: 99%

Atrial fibrillation: primary prevention, secondary prevention, and prevention of thromboembolic complications: part 1

Trohman

Huang

Sharma

2023

Front. Cardiovasc. Med.

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Atrial fibrillation (AF), is the most common sustained cardiac arrhythmia. It was once thought to be benign as long as the ventricular rate was controlled, however, AF is associated with significant cardiac morbidity and mortality. Increasing life expectancy driven by improved health care and decreased fertility rates has, in most of the world, resulted in the population aged ≥65 years growing more rapidly than the overall population. As the population ages, projections suggest that the burden of AF may increase more than 60% by 2050. Although considerable progress has been made in the treatment and management of AF, primary prevention, secondary prevention, and prevention of thromboembolic complications remain a work in progress. This narrative review was facilitated by a MEDLINE search to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1950 and 2021. Atrial fibrillation was searched via the terms primary prevention, hyperthyroidism, Wolff-Parkinson-White syndrome, catheter ablation, surgical ablation, hybrid ablation, stroke prevention, anticoagulation, left atrial occlusion and atrial excision. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. In these two manuscripts, we discuss the current strategies available to prevent AF, then compare noninvasive and invasive treatment strategies to diminish AF recurrence. In addition, we examine the pharmacological, percutaneous device and surgical approaches to prevent stroke as well as other types of thromboembolic events.

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Section: Evolving Concepts In Catheter Ablation Of Afmentioning

confidence: 99%

Atrial fibrillation: primary prevention, secondary prevention, and prevention of thromboembolic complications: part 1

Trohman

Huang

Sharma

2023

Front. Cardiovasc. Med.

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“…PVI + LAPWI with cryoballoon ablation has demonstrated consistent clinical outcomes, especially in randomized controlled trials [ 15 ]. There are several potential advantages to cryoablation [ 16 ]. First, lesions created using the cryoballoon are often larger.…”

Section: Introductionmentioning

confidence: 99%

“…For this reason, cryoballoon ablation offers a simple technique to ablate and debulk the LAPW. Moreover, cryoenergy can be considered safer with regard to anatomical structures that are close to the LAPW (i.e., the esophagus) [ 16 ].…”

Section: Introductionmentioning

confidence: 99%

Atrial Fibrillation Global Changes after Pulmonary Vein and Posterior Wall Isolation: A Charge Density Mapping Study

Pannone

Bisignani

Sorgente

et al. 2022

JCM

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Background: Non-contact charge density (CD) mapping allows a global visualization of left atrium (LA) activation and of activation patterns during atrial fibrillation (AF). The aim of this study was to analyze, with CD mapping, the changes in persistent AF induced by pulmonary vein isolation (PVI) and LA posterior wall isolation (LAPWI). Methods: Patients undergoing PVI + LAPWI using the Arctic Front Advance PROTM cryoballoon system were included in the study. CD maps were created during AF at baseline, after PVI and after LAPWI. Three distinct activation patterns were identified in the CD maps: localized irregular activation (LIA), localized rotational activation (LRA) and focal centrifugal activation (FCA). LA maps were divided into the following regions: anterior, septal, lateral, roof, posterior, inferior. Results: Eleven patients were included, with a total of 33 maps and 198 AF regions analyzed. Global and regional AF cycle lengths significantly increased after PVI and LAPWI. Baseline analysis demonstrated higher LIA, LRA and FCA numbers in the posterior and anterior regions. After PVI, there was no change in LIA, LRA and FCA occurrence. After PVI + LAPWI, a significant decrease in LRA was observed with no difference in LIA and FCA occurrence. In the regional analysis, there was a significant reduction in the LIA number in the inferior region, in the LRA number in the roof and posterior regions and in the FCA number in the lateral region. Conclusions: A global reduction in the LRA number was observed only after PVI + LAPWI; it was driven by a reduction in rotational activity in the roof and posterior regions.

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“…The posterior wall and the PVs are derived from the same mediastinal myocardium during embryological development, therefore the propensity for arrhythmogenicity within the posterior wall is not surprising. The cardiomyocytes in the PVs and posterior wall have unique electrophysiological properties related to sodium and calcium contents and potassium currents such that they have short action potentials, reduced resting membrane potentials, and are susceptible to spontaneous depolarizations 5–7 …”

Section: Introductionmentioning

confidence: 99%

“…The cardiomyocytes in the PVs and posterior wall have unique electrophysiological properties related to sodium and calcium contents and potassium currents such that they have short action potentials, reduced resting membrane potentials, and are susceptible to spontaneous depolarizations. [5][6][7] In addition to harboring triggers for inducing AF, the posterior wall can also serve as substrate for perpetuating AF. Heterogenous myocardial fiber orientation with the posterior wall results sets the stage for nonuniform anisotropy, which in turn can lead to conduction abnormalities including local reentry.…”

mentioning

confidence: 99%

The hybrid convergent procedure for persistent and long‐standing persistent atrial fibrillation from an electrophysiologist's perspective

Delurgio

2022

Cardiovasc electrophysiol

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In atrial fibrillation (AF), the pulmonary veins (PVs) are central to arrhythmogenicity and are targeted by PV isolation (PVI). As AF progresses, triggers become more prevalent in non‐PV areas including the left atrial posterior wall (LAPW). Reported benefits of LAPW isolation in Cox‐maze IV led to exploration of ablation strategies using endocardial catheters. However, no single approach to endocardial LAPW isolation exists. Relative success in comparison to PVI alone has been mixed. The hybrid convergent procedure was developed to combine minimally invasive surgical and electrophysiology techniques to accomplish effective PVI and LAPW isolation. Epicardial LAPW isolation is performed by a cardiothoracic surgeon followed by endocardial ablation by an electrophysiologist who ensures PVI completion and targets any remaining gaps. Safety and effectiveness of hybrid convergent were evaluated in the prospective, multicenter, randomized controlled trial, Convergence of Epicardial and Endocardial Ablation for the Treatment of Symptomatic Persistent AF (CONVERGE). CONVERGE compared the effectiveness of the hybrid convergent procedure to endocardial catheter ablation for treatment of drug‐refractory persistent and long‐standing persistent AF and demonstrated primary effectiveness of higher freedom from atrial arrhythmias absent new/increased dose previously failed/intolerant antiarrhythmic drugs through 12 months compared to endocardial catheter ablation. Greater freedom from AF and proportion of patients experiencing ≥90% burden reduction with hybrid convergent ablation were seen through 18 months of follow‐up. Improved electrophysiology lab efficiency was demonstrated by the reduction in endocardial ablation time with addition of epicardial ablation. This multidisciplinary heart team procedure may improve outcomes in difficult‐to‐treat patients with advanced AF.

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Rationale and Outcomes of Cryoballoon Ablation of the Left Atrial Posterior Wall in Conjunction with Pulmonary Vein Isolation

Cited by 5 publications

References 79 publications

Atrial fibrillation: primary prevention, secondary prevention, and prevention of thromboembolic complications: part 1

Atrial fibrillation: primary prevention, secondary prevention, and prevention of thromboembolic complications: part 1

Atrial Fibrillation Global Changes after Pulmonary Vein and Posterior Wall Isolation: A Charge Density Mapping Study

The hybrid convergent procedure for persistent and long‐standing persistent atrial fibrillation from an electrophysiologist's perspective

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