Balloon warming time is the strongest predictor of late pulmonary vein electrical reconnection following cryoballoon ablation for atrial fibrillation
Introduction
Pulmonary vein isolation (PVI) is an important component of atrial fibrillation (AF) ablation. Cryoballoon ablation is a standard method of achieving PVI.1 Acute PVI rates using cryoablation are in the range of 90%–100%,2, 3, 4, 5 and factors determining acute PVI using cryoballoon ablation have been investigated extensively.5, 6, 7, 8, 9, 10 Recurrence of AF following ablation is nearly always associated with pulmonary vein (PV) electrical reconnection.11, 12 However, limited data exist regarding the factors determining PV reconnection following cryoballoon ablation. We aimed to investigate factors determining PV reconnection in patients undergoing repeat catheter ablation for recurrent AF.
Section snippets
Methods
One hundred ninety-six patients underwent cryoballoon ablation for AF between April 2009 and November 2012 (derivation cohort). Characteristics of the initial ablation were systematically recorded. Of these patients, 51 underwent repeat electrophysiology studies after developing recurrent symptomatic AF. These consecutive patients constitute the study cohort. PVs were categorized as either persistently isolated or electrically reconnected. Characteristics of isolated and reconnected veins were
Results
Fifty-one patients underwent reassessment for recurrent symptomatic AF at a mean of 9 ± 5 months following the initial procedure. Of a total of 207 veins, 199 were treated by cryoablation alone and had data eligible for analysis. Of these, 91 had reconnected electrically to the left atrium (mean number of veins reconnected per patient = 1.8). All eligible veins remained isolated in 7 of 51 (14%) patients; a single vein had reconnected in 14 of 51 (27%) patients; 2 veins had reconnected in 16 of
Discussion
The most important novel finding from this study is that balloon warming time was the best predictor of PV reconnection. We found that an increased time taken for the balloon to warm following ablation was associated with an increased durability of PVI. There are at least 2 potential explanations for this finding. First, the balloon warming time is a simple measure of an effective cryoablation. Although the balloon temperature is not an accurate measure of absolute tissue temperature, it
Conclusions
Of the variables studied, we identified balloon warming time, vein occlusion score, and PV size as being independent predictors of late PV reconnection. Warming time appeared to be the most important single factor in predicting PV reconnection. Techniques that improve balloon/tissue contact and lengthening the warming time may result in an increased long-term success of cryoballoon ablation.
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2020, Heart RhythmCitation Excerpt :It is important to point out that at TTI, the cells have not necessarily reached a lethal freeze temperature, but the disappearance of PV potentials is indicative of circumferential cold propagation through the tissue, which has been studied as an indicator of lesion durability. A variety of parameters (eg, balloon-to-PV occlusion scores, balloon temperatures at various points during the freeze, freeze duration, and TTI) have been evaluated as intraprocedural predictors of durable PVI.20,21 In an analysis of PV reconnection in patients who underwent a repeat procedure after index cryoballoon PVI, neither the number nor the duration of freezes predicted PV reconnection.
Recurrent Atrial Fibrillation After Cryoballoon Ablation: What to Expect!
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2020, Heart Rhythm O2Citation Excerpt :Using the first-generation cryoballoon, the temperature at 120 seconds after ablation initiation was used to predict lesion durability. In these series, temperatures warmer than –36°C for superior PVs and warmer than –33°C for inferior PVs predicted ineffective PVI with >95% specificity (positive predictive value 80% for superior PVs and 82% for inferior PVs).22,23 As such, we consider lesions that fail to achieve a temperature colder than –35°C after 60 seconds ineffectual.24,25
Dr Ghosh is partly funded by the Friends of the Mater Foundation, North Sydney. Dr Singarayar is on the medical advisory committees for St Jude Medical and Medtronic. Dr McGuire has received honoraria from St Jude Medical and Medtronic for lectures.