Long-term outcomes after second-generation cryoballoon ablation of paroxysmal atrial fibrillation - Feasibility of a single short freeze strategy without bonus applications.
- 作者列表："Hara S","Miyazaki S","Hachiya H","Kajiyama T","Watanabe T","Nakamura H","Tada H","Iesaka Y
BACKGROUND:A paucity of data exists about long-term outcomes after second-generation cryoballoon ablation (2nd-CBA), and the feasibility of short freeze strategies remains under debate. We assessed the long-term follow-up outcomes. METHODS:This study included 186 paroxysmal atrial fibrillation (PAF) patients (62 ± 11 years, 136 men) who underwent 2nd-CBAs with a 28-mm balloon and single 3-min freeze strategy without bonus applications. Fourteen-day consecutive monitoring was performed to detect early AF recurrences (ERAFs). RESULTS:Overall, 713/736(96.9%) PVs were isolated with CBs. The total number of applications/patient was 5.3 ± 1.5. The total procedure and fluoroscopic times were 79.9 ± 28.1 and 24.4 ± 14.2 min. Asymptomatic right phrenic nerve injury occurred in 11 patients, however, all recovered during the follow-up. A total of 76(41.7%) patients experienced ERAFs. During a median 45.0 [30.0-51.0] month follow-up, the single procedure AF freedom was 76.1, 73.5, 70.5, and 63.7% at 1, 2, 3, and 4 years, respectively. At a median of 7.0 [4.0-12.0] months after the initial procedure, 35 (18.8%) patients underwent second procedures, and 106/137 (77.4%) PVs were still isolated. The multiple procedure AF freedom was 91.7, 89.3, 86.8, and 81.3% at 1, 2, 3, and 4 years, respectively. A Cox's proportional hazards model determined that the presence of ERAF was associated with a greater risk of recurrence after the last procedure (Hazard ratio = 2.830; 95% confidence interval = 1.173-6.833; p = 0.021). The percentage of continuation of anticoagulation therapy after the initial procedure was 33.1, 23.5, 21.7, and 21.7% at 1, 2, 3, and 4 years, respectively. CONCLUSIONS:Our long-term follow-up data demonstrated the feasibility of a single short freeze strategy in PAF patients.
背景: 关于第二代冷冻球囊消融 (2nd-CBA) 后长期结局的数据很少，短期冷冻策略的可行性仍在争论中。我们评估了长期随访结果。 方法: 本研究纳入 186 例阵发性房颤 (PAF) 患者 (62 ± 11 岁，136 例男性) 谁接受了第2-cba 与 28 毫米的气球和单一 3 分钟的冻结策略，没有奖金申请。进行 14 天连续监测以检测早期房颤复发 (ERAFs)。 结果: 总体而言，CBs 分离出 713/736 例 (96.9%) PVs。应用/患者总数为 5.3 ± 1.5。总手术和透视时间分别为 79.9 ± 28.1 和 24.4 ± 14.2 min。11 例患者出现无症状的右膈神经损伤，但随访期间均恢复。共有 76 例 (41.7%) 患者经历了 ERAFs。在中位 45.0 [30.0-51.0] 个月随访期间，1 、 2 、 3 和 4 年时，单次手术 AF 自由度分别为 76.1 、 73.5 、 70.5 和 63.7%, 分别。初次手术后中位时间为 7.0 [4.0-12.0] 个月，35 例 (18.8%) 患者接受了第二次手术，106/137 例 (77.4%) PVs 仍被隔离。在 1 、 2 、 3 和 4 年时，多次手术 AF 自由度分别为 91.7 、 89.3 、 86.8 和 81.3%。Cox 比例风险模型确定 ERAF 的存在与最后一次手术后更大的复发风险相关 (风险比 = 2.830; 95% 置信区间 = 1.173-6.833; p = 0.021)。初次手术后 1 、 2 、 3 和 4 年抗凝治疗的继续百分比分别为 33.1 、 23.5 、 21.7 和 21.7%。 结论: 我们的长期随访数据证明了 PAF 患者单一短期冷冻策略的可行性。
METHODS:AIMS:Pulmonary vein isolation (PVI) using ablation index (AI) incorporates stability, contact force (CF), time, and power. The CLOSE protocol combines AI and ≤6 mm interlesion distance. Safety concerns are raised about surround flow ablation catheters (STSF). To compare safety and effectiveness of an atrial fibrillation (AF) ablation strategy using AI vs. CLOSE protocol using STSF.,METHODS AND RESULTS:First cluster was treated using AI and second cluster using CLOSE. Procedural data, safety, and recurrence of any atrial tachycardia (AT) or AF >30 s were collected prospectively. All Classes 1c and III anti-arrhythmic drugs (AAD) were stopped after the blanking period. In total, all 215 consecutive patients [AI: 121 (paroxysmal: n = 97), CLOSE: n = 94 (paroxysmal: n = 74)] were included. Pulmonary vein isolation was reached in all in similar procedure duration (CLOSE: 107 ± 25 vs. AI: 102 ± 24 min; P = 0.1) and similar radiofrequency time (CLOSE: 36 ± 11 vs. AI: 37 ± 8 min; P = 0.4) but first pass isolation was higher in CLOSE vs. AI [left veins: 90% vs. 80%; P < 0.05 and right veins: 84% vs. 73%; P < 0.05]. Twelve-month off-AAD freedom of AF/AT was higher in CLOSE vs. AI [79% (paroxysmal: 85%) vs. 64% (paroxysmal: 68%); P < 0.05]. Only four patients (2%) without recurrence were on AAD during follow-up. Major complications were similar (CLOSE: 2.1% vs. AI: 2.5%; P = 0.87).,CONCLUSION:The CLOSE protocol is more effective than a PVI approach solely using AI, especially in paroxysmal AF. In this off-AAD study, 79% of patients were free from AF/AT during 12-month follow-up. The STSF catheter appears to be safe using conventional CLOSE targets.
METHODS:OBJECTIVE:To investigate the role of driver mechanism and the effect of electrogram dispersion-guided driver mapping and ablation in atrial fibrillation (AF) at different stages of progression.,METHODS:A total of 256 consecutive patients with AF who had undergone pulmonary vein isolation (PVI) plus driver ablation or conventional ablation were divided into three groups: paroxysmal atrial fibrillation (PAF; group A, n = 51); persistent atrial fibrillation (PsAF; group B, n = 38); and long standing-persistent atrial fibrillation (LS-PsAF; group C, n = 39). PVI was performed with the guidance of the ablation index. The electrogram dispersion was analyzed for driver mapping.,RESULTS:The most prominent driver regions were at roof (28.0%), posterior wall (17.6%), and bottom (21.3%). From patients with PAF to those with PsAF and LS-PsAF: the complexity of extra-pulmonary vein (PV) drivers including distribution, mean number, and area of dispersion region increased (P < .001). Patients who underwent driver ablation vs conventional ablation had higher procedural AF termination rate (76.6% vs 28.1%; P < .001). With AF progression, the termination rate gradually decreased from group A to group C, and the role of PVI in AF termination was also gradually weakened from group A to group C (39.6%, 7.4%, and 4.3%; P < .001) in patients with driver ablation. At the end of the follow-up, the rate of sinus rhythm maintenance was higher in patients with driver ablation than those with conventional ablation (89.1% vs 70.3%; P < .001).,CONCLUSION:The formation of extra-PV drivers provides an important mechanism for AF maintenance with their complexity increasing with AF progression. Electrogram dispersion-guided driver ablation appears to be an efficient adjunctive approach to PVI for AF treatment.
METHODS:PURPOSE:Whether or not pulmonary vein isolation (PVI) plus left atrial posterior wall isolation (PWI) using contact force (CF) sensing improves the ablation outcome for persistent atrial fibrillation (AF) is unclear. This study compared the outcome of PVI plus PWI and additional non-PV trigger ablation for persistent AF with/without CF sensing. METHODS:This retrospective cohort study analyzed 148 propensity score-matched persistent AF patients (median duration of persistent AF, 8 months (interquartile range, 3-24 months); left atrial diameter, 43 ± 7 mm) undergoing PVI plus PWI and ablation of non-PV triggers provoked by high-dose isoproterenol, including 74 with CF-sensing catheters (CF group) and 74 with conventional catheters (non-CF group). PVI plus PWI with no additional ablation but cavotricuspid isthmus ablation was performed without non-PV triggers in 48 CF patients (65%) and 54 non-CF patients (73%) (P = 0.38). In all other patients, we performed additional ablation of provoked non-PV triggers. RESULTS:The Kaplan-Meier estimate of the rate of freedom from atrial tachyarrhythmia recurrence of antiarrhythmic drugs at 12 months after the single procedure was higher in the CF group than in the non-CF group (85 vs. 70%, log-rank P = 0.030). A multivariable analysis revealed that using CF sensing and non-inducibility of AF from a non-PV trigger after PVI and PWI were significantly associated with a reduced rate of atrial tachyarrhythmia recurrence. CONCLUSIONS:Compared with non-CF sensing, PVI plus PWI and additional non-PV trigger ablation using CF-sensing catheters for persistent AF can reduce the rate of atrial tachyarrhythmia recurrence.