Second‐generation cryoballoon ablation for recurrent atrial fibrillation after an index procedure with radiofrequency versus cryo: Different pulmonary vein reconnection patterns but similar long‐term outcome—Results of a multicenter analysis

Abstract

Introduction: Repeated procedures are often needed for long-term success of atrial fibrillation ablation. There are scarce data regarding cryoballoon use for such procedure. Methods and Results:We analyzed acute effect and long-term follow-up of secondgeneration cryoballoon ablation, performed as a repeat procedure after an index radiofrequency vs cryoballoon ablation. Sixty-one patients from three centers were included. In 36 cases radiofrequency (RF-I) and in 25 cryoballoon ablation (CB-I) was the index procedure. During redo procedure, pulmonary vein reconnection was less frequent in CB-I vs RF-I (51.5% vs 66.9%; P = 0.017). After cryoballoon, left inferior (P = 0.027) and right superior (P = 0.06) pulmonary veins were less likely to exhibit reconnection. Moreover, patients after initial RF ablation frequently presented multiple-vein reconnection (P = 0.018), while patients after cryoablation more often had only one vein reconnected (P = 0.008).During reablation procedures, all 149 reconnected veins in both groups were isolated, with no differences in procedural parameters, except for procedure time, shorter in CB-I group (65.5 vs 71.1 minutes; P = 0.04). Transient phrenic nerve palsy was the only complication in both groups (5.6% and 8.0%; ns). After mean follow-up of 15 ± 9 months, 70.3% of patients were free from atrial fibrillation (AF), with no differences between the groups (P = 0.71). In multivariate Cox-regression analysis, the persistent form of arrhythmia (P = 0.009) and relapse in the blanking period (P = 0.0004) were the only independent predictors of AF recurrence. Conclusions:The use of second-generation cryoballoon is associated with less frequent pulmonary vein reconnection compared with RF ablation. Cryoballoon is safe and effective for repeated AF ablation, regardless of the technique used for the initial procedure. K E Y W O R D S atrial fibrillation, cryoballoon ablation, pulmonary vein reconnection, redo ablation

Comparison of pulmonary vein reconnection patterns after multielectrode phased radiofrequency- and cryoballoon ablation of atrial fibrillation

“…In our study PV reconnections after CB PVI were most frequently observed in LSPVs. This finding is consistent with data presented by Shah et al and Glowniak et al [12,16], while Aryana et al found CTs most frequently reconnected after CB PVI [3]. The anatomical ridge between LSPV and LAA, a common reconnection site with increased wall thickness, reduces the creation of a complete transmural lesion and thus may result in frequent reconnections of the left superior PV.…”

“…Reconnection patterns at redo PVI after PVAC ablation were very similar with those reported after point-by point ablation and differ from CB reconnection patterns in many aspects. Comparable with reported reconnection rates of 67% after conventional point-by point PVI, [16] we found 75% PVs reconnected, with multiple PV reconnections per patient and 66% of the patients (61%, reported by Glowniak et al [16]) showing ≥3 reconnected PVs. PVAC lesions around the PV ostium are known to be less homogeneous compared with CB lesions created with 2nd generation CB, which contributes to the observed differences in PV reconnection patterns.…”

Is the Time of Atrial Fibrillation Recurrence After Duty-Cycled Radiofrequency Ablation Affected by the Pattern of Pulmonary Vein Reconnections?

“…In our study PV reconnections after PVAC PVI were most frequently observed in CTs and LSPVs. This finding is consistent with data from CB ablation presented by Shah et al and Glowniak et al [11,12], while Aryana et al found that CTs most frequently reconnected after CB PVI [9].…”

Pulmonary vein reconnection following cryo-ablation: Mind the “Gap” in the carinae and the left atrial appendage ridge

“…The authors suggested that the carina area between PVs and the thicker tissue in the LAA ridge could be responsible for suboptimal creation of transmural lesions in these sites accounting for the higher PVR occurrence in these regions [3]. Other investigators have also pointed to the LSPV as the most common site of PVR regardless of the method employed during the index procedure, and have attributed it to the specific anatomy of the ridge between the LSPV and the LAA [6,12,13]. During point-by-point RF ablation it is often difficult to achieve and maintain stable catheter position and apply adequate contact force in this region.…”