Pulmonary Vein Isolation With and Without Posterior Wall Isolation in Paroxysmal Atrial Fibrillation: IMPPROVE-PAF Trial

Pulsed field ablation technology for pulmonary vein and left atrial posterior wall isolation in patients with persistent atrial fibrillation

INTRODUCTION

Limited data exist on pulsed-field ablation (PFA) in patients with persistent atrial fibrillation (PeAF) undergoing left atrial posterior wall isolation (LAPWI).

METHODS

The Advanced TecHnologies For SuccEssful AblatioN of AF in Clinical Practice (ATHENA) prospective registry included consecutive patients referred for PeAF catheter ablation at 9 Italian centers, treated with the FARAPULSETM-PFA system. The primary efficacy and safety study endpoints were the acute LAPWI rate, freedom from arrhythmic recurrences and the incidence of major periprocedural complications. Patients undergoing pulmonary vein isolation (PVI) alone, PWI + LAPWI and redo procedures were compared.

RESULTS

Among 249 patients, 21.7% had long-standing PeAF, 79.5% were male; mean age was 63 ± 9 years. LAPWI was performed in 57.6% of cases, with 15.3% being redo procedures. Median skin-to-skin times (PVI-only 68 [60-90] vs. PVI + LAPWI 70 [59-88] mins) did not differ between groups. 45.8% LAPWI cases were approached with a 3D-mapping system, and 37.3% with intracardiac echocardiography. LAPWI was achieved in all patients by means of PFA alone, in 88.8% cases at first pass. LAPWI was validated either by an Ultrahigh-density mapping system or by recording electrical activity + pacing maneuvers. No major complications occurred, while 2.4% minor complications were detected. During a median follow-up of 273 [191-379] days, 41 patients (16.5%) experienced an arrhythmic recurrence after the 90-day blanking period, with a mean time to recurrence of 223 ± 100 days and no differences among ablation strategies.

CONCLUSION

LAPWI with PFA demonstrates feasibility, rapidity, and safety in real-world practice, offering a viable alternative for PeAF patients. LAPWI is achievable even with a fluoroscopy-only method and does not significantly extend overall procedural times.

Intracardiac echocardiography guided simultaneous atrial fibrillation ablation and Micra implantation 14 days after Watchman FLX implantation

Key Clinical Message

Atrial fibrillation ablation, including pulmonary vein isolation immediately after left atrial appendage closure (LAAC), is a rare and challenging issue. Intracardiac echocardiography guidance can help identify the LAAC device position for safe atrial fibrillation ablation without LAAC device-related adverse events even immediately after LAAC device implantation.

Abstract

Early phase atrial fibrillation (AF) ablation after left atrial appendage closure (LAAC) is a rare and challenging issue. Here, we present a case illustrating the feasibility of AF ablation under intracardiac echocardiography guidance immediately after LAAC device implantation without LAAC device-related adverse events.

Cryoballoon ablation of non-PV triggers in persistent atrial fibrillation

Cryoballoon-based catheter ablation has emerged as an efficacious and safe therapeutic intervention for patients with paroxysmal atrial fibrillation (PAF). PAF is primarily associated with the triggers in the pulmonary vein (PV). However, persistent atrial fibrillation (PeAF) is a complex condition that involves changes in the atrial substrate and the presence of non-PV triggers. Therefore, a comprehensive treatment approach is necessary for patients with PeAF. Utilizing a 3D electroanatomical map, the radiofrequency-based ablation technique adeptly identifies and targets the atrial substrate and non-PV triggers. On the other hand, the cryoballoon-based AF ablation was initially designed for PV isolation. However, its single-shot feature makes it a great choice for electrophysiologists looking to address non-PV triggers. It is possible to target the left atrial appendage (LAA), superior vena cava (SVC), left atrial roof, and posterior wall using the apparatus's unique configuration and ablation abilities. This review focuses on the increasing literature regarding cryoballoon-based methods for non-PV trigger ablation. Specifically, it delves into the technical procedures used to isolate the LAA, SVC, and ablate the left atrial roof and posterior wall.

Modification of the pulmonary vein antrum is associated with recurrence after durable pulmonary vein isolation for paroxysmal atrial fibrillation

BACKGROUND

Although previous studies have shown the isolated areas after pulmonary vein isolation (PVI) using cryoballoons (CB) (CB-PVI), no studies have investigated the association between the isolated area and recurrence of atrial fibrillation (AF) and atrial tachycardia (AT). This single-center observational study investigated the association between the ablated area and recurrence rate after durable CB-PVI for paroxysmal AF.

METHODS

This study included 76 patients with paroxysmal AF who underwent CB-PVI and established durable PVI with a second procedure, regardless of AF/AT recurrence, 6 months after the first procedure. To compare the ablated zones, we quantified the left- and right-sided PV antral isolation areas and non-ablated posterior wall (PW) area. We examined non-ablated areas of the PW and AF/AT recurrence in the chronic phase.

RESULTS

In total, 16 of the 76 patients had AF/AT recurrence. The mean follow-up duration was 34 months. The non-ablated PW area (14.0 ± 4.6 cm2 vs. 11.5 ± 3.7 cm2; p = 0.0213) and the ratio of the non-ablated PW area to the whole PW area (NAPW) (52.9 ± 9.1% vs. 44.8 ± 9.8%; p = 0.003) were significantly higher in the AF/AT recurrence group than in the AF/AT non-recurrence group. NAPW > 50% was an independent predictor of AF/AT recurrence.

CONCLUSION

The NAPW after durable CB-PVI is associated with AF/AT recurrence. PW isolation or additional applications on the PV antrum with cryoballoon may be considered in addition to PVI in paroxysmal AF, especially in patients with dilated left atria.

Adjunct posterior wall isolation reduces the recurrence of atrial fibrillation in patients undergoing cryoballoon ablation: A systematic review and meta-analysis

BACKGROUND

Recurrence rates of atrial fibrillation (AF) remain high even after complete wide area circumferential pulmonary vein isolation (PVI). In recent years adjunct posterior wall isolation (PWI) has been performed in patients with more persistent forms of AF but the benefits remain unclear.

AIM

The objective of this meta-analysis was to evaluate the efficacy of adjunct posterior wall isolation in reducing recurrence rates of AF using cryoballoon ablation (CBA).

METHODS

We searched PubMed, Google Scholar, Clinicaltrials.gov and Cochrane CENTRAL. We included studies comparing PVI to PVI + PWI in patients with either persistent or paroxysmal AF (PAF) undergoing CBA. After data extraction and quality assessment of the studies, we assessed recurrence rates of atrial tachy-arrhythmias (AF, atrial flutter, and atrial tachycardia) as well as total ablation time and procedural adverse events. Risk ratio (RR), mean difference (MD), and 95% confidence interval (CI) were calculated using Review Manager.

RESULTS

Concomitant PWI exhibited a substantial reduction in the risk of AF recurrence (RR: 0.51; 95% CI: 0.42-0.63, p < .00001), as well as all atrial arrhythmias (RR: 0.58; 95% CI: 0.49-0.68, p < .00001). On subgroup analysis, in patients with only PAF, adjunct PWI resulted in significant reduction in recurrence risk of AF (RR: 0.56; 95% CI: 0.41-0.76, p = .0002) as well. There was no significant difference in adverse events between both groups (RR: 0.90; 95% CI: 0.44-1.86; p = .78), whereas total ablation time was significantly increased in PVI + PWI group (MD: 21.75; 95% CI: 11.13-32.37, p < .0001).

CONCLUSION

Adjunct PWI when compared to PVI alone decreases recurrence rates of atrial fibrillation after CBA of patients with persistent as well as paroxysmal atrial fibrillation.

Outcomes of adjunct posterior wall isolation in atrial fibrillation patients with cardiac implantable electronic devices

BACKGROUND

Although pulmonary vein isolation (PVI) remains the cornerstone of catheter ablation of atrial fibrillation (AF), several studies have illustrated clinical benefits associated with PVI with posterior wall isolation (PWI).

METHODS

This retrospective study investigated the outcomes of PVI alone versus PVI+PWI performed using the cryoballoon in patients with cardiac implantable electronic devices (CIEDs) and paroxysmal AF (PAF) or persistent AF (PersAF).

RESULTS

Acute PVI was achieved in all patients using cryoballoon ablation. Compared to PVI alone, PVI+PWI was associated with longer cryoablation, fluoroscopy, and total procedure times. Adjunct radiofrequency was required to complete PWI in 29/77 patients (37.7%). Adverse events were similar with PVI alone versus PVI+PWI. But at 24 ± 7 months of follow-up, not only cryoballoon PVI+PWI was associated with improved freedom from recurrent AF (74.3% vs. 46.0%, P = .007) and all atrial tachyarrhythmias (71.4% vs. 38.1%, P = .001) in patients with PersAF, cryoballoon PVI+PWI also yielded greater freedom from AF (88.1% vs. 63.7%, P = .003) and all atrial tachyarrhythmias (83.3% vs. 60.8%, P = .008) in those with PAF. Additionally, PVI+PWI was associated with higher reductions in atrial tachyarrhythmia burden (97.9% vs. 91.6%, P < .001), need for cardioversion (5.2% vs. 23.6%, P < .001) and repeat catheter ablation (10.4% vs. 26.1%, P = .005), and a longer time-to-arrhythmia recurrence (16 ± 6 months vs. 8 ± 5 months, P < .001) in both PersAF and PAF patients.

CONCLUSION

In CIED patients with PersAF or PAF, cryoballoon PVI+PWI is associated with a greater freedom from recurrent AF and atrial tachyarrhythmias, as compared to PVI alone during long-term follow-up.