Abstract

Research Article

Recurrence of atrial fibrillation after pulmonary vein isolation, should we change the energy and technique?

Jorge Toquero Ramos*, Alejandro Durante-López, Jesús González Mirelis, Víctor Castro Urda, Eusebio García Izquierdo, Diego Jiménez Sánchez and Ignacio Fernández-Lozano

Published: 03 April, 2020 | Volume 5 - Issue 1 | Pages: 073-079

Background: Pulmonary vein isolation (PVI) is the accepted standard nowadays for atrial fibrillation (AF) ablation. The most widespread ablation techniques are cryoballoon (CB) and point-by-point radiofrequency (RF) ablation. Comparative studies between both techniques have shown their equivalence for the first ablation procedure, but no trial has explored the potential incremental benefit of crossing over the ablation technique after AF recurrence.

Objective: To explore the potential incremental benefit of a crossover ablation strategy for AF recurrences, comparatively with repeating the same ablation energy used for the first procedure.

Methods: Retrospective analysis of patients undergoing a second AF ablation procedure after documented AF recurrence. Patients were excluded if all 4 PV were isolated at the beginning of the second procedure or extra-PVI ablation was used for the second procedure. Crossover group (n = 16) included patients in which two different techniques were used for the first and second procedure (CB-RF or RF-CB). Control group (n = 23) for those with same ablation procedure (RF-RF of CB-CB). Acute procedure end-point was PVI of all four pulmonary veins. Patients were followed-up at 3, 6, and 12 months with an electrocardiogram and a 24 h-holter. Arrhythmia-free survival at 1 year after the second ablation procedure was studied, comparing efficiency and safety of the two approaches (crossover vs. same energy). Success was defined as freedom from AF or atrial tachycardia lasting > 30 s off antiarrhythmic drugs (AADs)

Results: A cohort of 39 paroxysmal and persistent AF patients was analyzed. PVI after the second procedure was 100% in all patients in both groups. There were no baseline relevant differences between the two groups. No deaths or hospitalizations occurred during follow up (data censored at 24h moths). At 1 year, arrhythmia free-survival was significantly higher in the crossover group compared to control group [93,3% vs. 47,8%; HR 0.19 (0.06-0.66);p = 0,009].

Conclusion: Crossing the ablation technique (point-by-point radiofrequency or cryoballoon PVI) after AF recurrence significantly improved arrhythmia free-survival at one year, despite no difference in acute success (PVI isolation). Randomized controlled trials with a higher amount of patients are needed to confirm the results and widespread this approach.

Read Full Article HTML DOI: 10.29328/journal.jccm.1001090 Cite this Article Read Full Article PDF

Keywords:

Atrial fibrillation ablation; Pulmonary vein isolation; Cryoablation; Radiofrequency; Crossover strategy

References

  1. Stewart S, Hart CL, Hole DJ, McMurray JJ. A Population-Based Study of the Long-Term Risks Associated with Atrial Fibrillation: 20-Year Follow-up of the Renfrew/Paisley Study. Am J Med. 2002: 113: 359–364. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/12401529
  2. Lafuente-Lafuente C1, Valembois L, Bergmann JF, Belmin J. Antiarrhythmics for Maintaining Sinus Rhythm after Cardioversion of Atrial Fibrillation. Cochrane Database Syst Rev. 2015; CD005049. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/25820938
  3. Kirchhof P Benussi S1, Kotecha D, Ahlsson A, Atar D, et al. 2016 ESC Guidelines for the Management of Atrial Fibrillation Developed in Collaboration with EACTS. Eur Heart J. 2016; 50:, e1-e88. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27663299
  4. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014; 64: e1-76. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/24685669
  5. Squara F, Zhao A, Marijon E, Latcu DG4 Providencia R, et al. Comparison between Radiofrequency with Contact Force-Sensing and Second-Generation Cryoballoon for Paroxysmal Atrial Fibrillation Catheter Ablation: A Multicentre European Evaluation. Europace. 2015; 17: 718–724. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/25840289
  6. Kuck KH, Brugada J, Fürnkranz A, Metzner A, Ouyang F, et al. Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation. N Engl J Med. 2016; 374: 2235–2245. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27042964
  7. Yokokawa M, Chugh A, Latchamsetty R, Ghanbari H, Crawford T, et al. Cryoballoon Antral Pulmonary Vein Isolation vs. Force-Sensing Radiofrequency Catheter Ablation for Pulmonary Vein and Posterior Left Atrial Isolation in Patients with Persistent Atrial Fibrillation. Heart Rhythm. 2018; 15: 1835-1841. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/30509365
  8. Schmidt M, Dorwarth U, Andresen D, Brachmann J, Kuck KH, et al. Cryoballoon versus RF Ablation in Paroxysmal Atrial Fibrillation: Results from the German Ablation Registry. J Cardiovasc Electrophysiol. 2014; 25: 1–7. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/24134539
  9. Fitzgerald DM. Catheter Ablation of Atrial Fibrillation: To Freeze, or Not to Freeze, That Is the Question. J Cardiovasc Electrophysiol. 2014; 25: 8–10. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/24112780
  10. Luik A, Radzewitz A, Kieser M, Walter M, Bramlage P, et al. Cryoballoon Versus Open Irrigated Radiofrequency Ablation in Patients With Paroxysmal Atrial Fibrillation: The Prospective, Randomized, Controlled, Noninferiority FreezeAF Study. Circulation. 2015; 132: 1311–1319. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/26283655
  11. Wasserlauf J, Pelchovitz DJ, Rhyner J, Verma N, Bohn M, et al. Cryoballoon versus Radiofrequency Catheter Ablation for Paroxysmal Atrial Fibrillation. Pacing Clin Electrophysiol. 2015; 38: 483–489. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/25627795
  12. Koch L, Haeusler KG, Herm J, Safak E, Fischer R, et al. Mesh Ablator vs. Cryoballoon Pulmonary Vein Ablation of Symptomatic Paroxysmal Atrial Fibrillation: Results of the MACPAF Study. Europace. 2012; 14: 1441–1449. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22523379
  13. Kuck KH, Fürnkranz A, Chun KR, Metzner A, Ouyang F, et al. Cryoballoon or Radiofrequency Ablation for Symptomatic Paroxysmal Atrial Fibrillation: Reintervention, Rehospitalization, and Quality-of-Life Outcomes in the FIRE and ICE Trial. Eur Heart J. 2016; 37: 2858–2865. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27381589
  14. Natale A, Nielsen JC. To Burn or to Freeze: A Burning Question yet to Be Resolved. Eur Heart J. 2016; 37: 2866–2868. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27593103
  15. Mugnai G, Sieira J, Ciconte G, Hervas MS, Irfan G, et al. One Year Incidence of Atrial Septal Defect after PV Isolation: A Comparison between Conventional Radiofrequency and Cryoballoon Ablation. Pacing Clin Electrophysiol. 2015; 38: 1049–1057. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/25974316
  16. Providencia R, Defaye P, Lambiase PD, Pavin D, Cebron JP, et al. Results from a Multicentre Comparison of Cryoballoon vs. Radiofrequency Ablation for Paroxysmal Atrial Fibrillation: Is Cryoablation More Reproducible? Europace. 2017; 19: 48–57. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27267554
  17. Miyazaki S1, Hachiya H1, Nakamura H1, Taniguchi H1, Takagi T, et al. Pulmonary Vein Isolation Using a Second-Generation Cryoballoon in Patients With Paroxysmal Atrial Fibrillation: One-Year Outcome Using a Single Big-Balloon 3-Minute Freeze Technique. J. Cardiovasc. Electrophysiol. 2016; 27: 1375–1380. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27534931
  18. Verma A, Jiang CY, Betts TR, Chen J, Deisenhofer I, et al. Approaches to Catheter Ablation for Persistent Atrial Fibrillation. N Engl J Med. 2015; 372: 1812–1822. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/25946280
  19. Providência R, Lambiase PD, Srinivasan N, Ganesh Babu G, Bronis K, et al. Is There Still a Role for Complex Fractionated Atrial Electrogram Ablation in Addition to Pulmonary Vein Isolation in Patients with Paroxysmal and Persistent Atrial Fibrillation? Circ Arrhythmia Electrophysiol. 2015; 8: 1017–1029. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/26082515
    1. Siu CW, Tse HF. Thromboembolic Risk of the Hot- and Cold-Catheter Ablation for Atrial Fibrillation. Hear Rhythm. 2012; 9: 197–198. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/21978961

Figures:

Figure 1

Figure 1

Figure 1

Figure 2

Similar Articles

  • Recurrence of atrial fibrillation after pulmonary vein isolation, should we change the energy and technique?
    Jorge Toquero Ramos*, Alejandro Durante-López, Jesús González Mirelis, Víctor Castro Urda, Eusebio García Izquierdo, Diego Jiménez Sánchez and Ignacio Fernández-Lozano Jorge Toquero Ramos*,Alejandro Durante-López,Jesús González Mirelis,Víctor Castro Urda,Eusebio García Izquierdo,Diego Jiménez Sánchez,Ignacio Fernández-Lozano. Recurrence of atrial fibrillation after pulmonary vein isolation, should we change the energy and technique?. . 2020 doi: 10.29328/journal.jccm.1001090; 5: 073-079
  • An unusual presentation of atrioventricular nodal reentrant tachycardia
    Mihaela Grecu*, Florina-Adriana Ghitun, Stefan Ailoaei, Dan Ursu, Raluca Chistol, Grigore Tinica and Cristian Statescu Mihaela Grecu*,Florina-Adriana Ghitun,Stefan Ailoaei,Dan Ursu,Raluca Chistol,Grigore Tinica,Cristian Statescu. An unusual presentation of atrioventricular nodal reentrant tachycardia. . 2021 doi: 10.29328/journal.jccm.1001110; 6: 014-018

Recently Viewed

Read More

Most Viewed

Read More

Help ?