Acute efficacy and clinical outcomes using HotBalloon for pulmonary vein isolation in patients with a left common pulmonary vein

Impact of the left common ostium following pulmonary vein isolation in AF : Systematic review and meta‐analysis

Purpose

Pulmonary vein isolation (PVI) through catheter ablation is the basis for the treatment of atrial fibrillation (AF). The left common ostium (LCO) is a high prevalence anatomical variation and has conflicting results in the effects on the prognosis following ablation. We undertook a systematic review and meta‐analysis of studies that compared the arrhythmia recurrence rate after radiofrequency ablation or cryoablation balloon between patients with normal pattern pulmonary vein and patients with LCO.

Methods and Results

Results were pooled using a fixed or random effect, at the discretion of heterogeneity (>25%), in addition, we associated subgroup analysis in these cases and when clinically indicated. Fourteen non‐randomized studies totaling 3278 patients were included. In analyses using the two energies all patients: OR 1.01 (95% CI 0.84–1.23; P = .90, I² = 67%) and excluding patients with any type of persistent AF (PeAF) and those submitted to linear atrial lesion (LAL) OR 0.80 (95% CI 0.52–1.22; P = .30, I² = 71%). Using CRYO: all patients OR 1.34 (95% CI 1.03–1.74; P = .03, I² = 0%). Using RF: all patients—OR 0.55 (95% CI 0.32–0.95; P = .03, I² = 49%); excluding studies with long duration PeAF and the performance of LAL concomitant—OR 0.45 (95% CI 0.23–0.91; P = .03, I² = 44%).

Conclusion

The results suggest a better prognosis in patients with LCO, submitted to PVI without additional LAL under RF energy in paroxysmal AF and short‐duration PeAF. In patients undergoing CRYO, the presence of LCO suggests a worse prognosis.

Pulmonary vein stenosis after HotBalloon pulmonary vein isolation of paroxysmal atrial fibrillation

HotBalloon-based pulmonary vein isolation (HBPVI) has yielded encouraging clinical results in the treatment of paroxysmal atrial fibrillation (PAF). However, pulmonary vein (PV) stenosis remains a concern. The influence of longer application duration on PV stenosis has not yet been systematically evaluated. All patients who underwent first HBPVI of PAF with pre- and post-ablation computed tomography (CT) were included. We used single-shot technique with application duration of 180 s in the RSPV, 180-240 s in the LSPV, and 120 s in the lower PV procedures. PV stenosis was analyzed using CT and categorized as moderate (50-70%), and severe (> 70%) reduction in PV diameter. We analyzed imaging of the PV anatomy before ablation and during follow-up in 84 patients. Among them, 7 (8.3%) showed moderate stenosis, and 3 (3.6%) had severe stenosis including one total occlusion patient. All severe stenosis and total occlusion occurred in RSPV and LSPV procedures with longer application duration. No severe stenosis nor total PV occlusion occurred in inferior PV procedures with shorter application duration. The incidence of PV stenosis ≥ 50% or total PV occlusion was significantly lower in inferior PV than RSPV and LSPV procedures (0.6%, 6.0%, 8.0%, p = 0.01, respectively). All cases of PV stenosis including total PV occlusion patients were asymptomatic. No intervention for PV stenosis was performed. The risk of PV stenosis in HBPVI was rare in lower PV procedure with shorter application duration. An application duration setting of 120 s in lower PV procedure might be effective to prevent PV stenosis.