Long-term outcomes of index cryoballoon ablation or point-by-point radiofrequency ablation in patients with atrial fibrillation and systolic heart failure

The efficacy and safety of cryoballoon atrial fibrillation ablation in patients with heart failure: A systematic review and meta-analysis

INTRODUCTION

While atrial fibrillation (AF) ablation has proven beneficial for heart failure (HF) patients, most reports were performed with radiofrequency ablation. We aimed to evaluate the efficacy and safety of cryoballoon AF ablation in patients with HFrEF.

METHOD

We comprehensively searched the databases of MEDLINE, EMBASE, and Cochrane database from inception to December 2022. Studies that reported the outcomes of freedom from atrial arrhythmia, complications, NYHA functional class (NYHA FC), and left ventricular ejection fraction (LVEF) after Cryoballoon AF ablation in HF patients were included. Data from each study were combined with a random-effects model.

RESULT

A total of 9 studies observational studies with 1414 HF patients were included. Five studies had only HF with reduced ejection fraction (HFrEF), 1 study with HF with preserved ejection fraction (HFpEF), and others with mixed HF types. Freedom from AA in HFrEF at 12 months was 64% (95% CI 56-71%, I2 58%). There was a significant improvement of LVEF in these patients with a standard mean difference of 13% (95% CI 8.6-17.5%, I2 99% P < 0.001. The complication rate in HFrEF group was 6% (95% CI 4-10%, I2 0%). The risk of recurrence of atrial arrhythmia was not significantly different between HF and no HF patients (RR 1.34, 95% CI 0.8-2.23, I2 76%).

CONCLUSION

Cryoballoon AF ablation is effective in HFrEF patients comparable to radiofrequency ablation. The complication rate was low.

Cryoballoon ablation for atrial fibrillation in patients with heart failure and reduced left ventricular ejection fraction: A systematic review and meta-analysis

The coexistence of atrial fibrillation (AF) with heart failure (HF) is prevalent, leading to severe complications. This review aimed to investigate the success rate and efficacy of cryoballoon ablation (CBA) by measuring the improvement in the New York Heart Association (NYHA) classification and the effect on the left ventricular systolic function in patients with AF accompanied by heart failure with reduced ejection fraction (HFrEF). Electronic databases search included PubMed, Web of Science, and Scopus in January 2023. Outcomes addressed the following: left ventricular ejection fraction (LVEF) improvement, AF recurrence, NYHA classification improvement, and mortality. STATA 17.0 software was used for data analysis. The effect size for the studies was a standard mean difference (SMD) with a 95% confidence interval (CI) for outcomes. Proportion analysis with 95% CI was used for freedom from early AF and AF after 2 years and all-cause death. We included six studies, including 1699 HF patients with 365 HFrEF patients. The SMD of postoperative LVEF compared to preoperative LVEF in HFrEF was 0.99 ([95% CI: 0.60, 1.39], p = .00), and for NYHA was -1.12 ([95% CI: -1.36, -0.87], p = .00). The analysis results in HFrEF patients for freedom from AF after 1 year was 65% ([95% CI: 0.55, 0.75], and after 2 years was 39% ([95% CI: 0.10, 0.67]). Proportional analysis was conducted for all-cause death, resulting in 3% mortality ([95% CI: -0.01, 0.07]). Cryoablation of AF accompanied by HFrEF appeared safe as it reduced AF recurrence and enhanced clinical outcomes.

Best Practice Guide for Cryoballoon Ablation in Atrial Fibrillation: The Compilation Experience of More than 1000 Procedures

Nowadays, the cryoballoon (CB) constitutes an established alternative to radio frequency (RF) ablation for pulmonary vein isolation (PVI), which offers the possibility to isolate the PVs with a single application. Since the introduction of the second-generation CB, we prospectively collected our data to optimize the procedure on >1000 consecutive patients who underwent CB PVI performed in our center. It is expected that subsequent guidelines will suggest first-line PVI through CB in patients with paroxysmal AF with a class I indication. Indeed, in the long-term follow-up (36 months) of the EARLY-AF trial, CB had a lower incidence of persistent atrial fibrillation episodes compared to the anti-arrhythmic drugs group. We now review the current best practices in an effort to drive consistent outcomes and minimize complications. PV isolation through CB is the most studied single-shot technique for atrial fibrillation ablation, having shown the potential to alter the natural history of the arrhythmia. Several procedural tips and tricks can improve procedural flow and effectiveness. In the present article we provided not only technical details but measurable biophysical parameters that can reliably guide the operator into achieving the best outcome for his patients.

PolarX Cryoballoon metrics predicting successful pulmonary vein isolation: targets for ablation of atrial fibrillation

AIM

Evaluate the novel PolarX Cryoballoon in atrial fibrillation (AF) catheter ablation through a propensity-matched comparison with the Arctic Front Advance (AFA). The aim was also to identify cryoablation metrics that are predictive of successful pulmonary vein isolation (PVI) with the PolarX Cryoballoon.

METHODS AND RESULTS

This prospective multi-centre study included patients that underwent cryoablation for AF. All patients underwent PVI with reconnection assessed after a 30-min waiting period and adenosine. Safety, efficacy, and cryoablation metrics were compared between PolarX and a propensity-matched AFA cohort. Seventy patients were included with 278 veins treated. In total, 359 cryoablations were performed (1.3 ± 0.6 per vein) to achieve initial PVI with 205 (73.7%) veins isolating with a single cryoablation. Independent predictors for achieving initial PVI included temperature at 30 s [odds ratio (OR) 1.26; P = 0.003] and time to reach -40°C (OR 1.88; P < 0.001) with an optimal cut-off of ≤-38.5°C at 30 s [area under the curve (AUC) 0.79; P < 0.001] and ≤-40°C at ≤32.5 s (AUC 0.77; P < 0.001), respectively. Of the 278 veins, 46 (16.5%) veins showed acute reconnection. Temperature at 30 s (≤-39.5°C, OR 1.24; P = 0.002), nadir temperature (≤-53.5°C, OR 1.35; P = 0.003), and time to isolation (≤38.0 s, OR 1.18; P = 0.009) were independent predictors of sustained PVI. Combining two of these three targets was associated with reconnection in only 2-5% of PVs. Efficacy and safety of the PolarX Cryoballoon were comparable to AFA Cryoballoon, however, cryoablation metrics were significantly different.

CONCLUSIONS

The PolarX Cryoballoon has a different cryoablation profile to AFA Cryoballoon. Prospective testing of these proposed targets in large outcomes studies is required.

Effects of Modified Simultaneous Unipolar Saline-Irrigated Radiofrequency Ablation in Patients with Atrial Fibrillation Combined with Mitral Valve Disease

Objective

To investigate the therapeutic effects of a modified simultaneous unipolar saline-irrigated radiofrequency ablation by intracardiac operation under direct vision in patients with mitral valve diseases combined with atrial fibrillation (AF).

Methods

A total of 168 patients with mitral valve diseases combined with AF who underwent unipolar saline-irrigated radiofrequency ablation modified maze procedures were enrolled and divided into the mitral stenosis (MS) group (n = 87) and the mitral insufficiency (MI) group (n = 81).

Results

Those with a left atrium diameter (LAD) < 55 mm had a better cardioversion effect during the mid-term post-operation than those with a LAD ≥ 55 mm (P < 0.05). The cardioversion effect during the mid-term post-operation was better in those with a duration of AF < 2 years than those with AF ≥ 2 years (P < 0.05). The LAD reduced significantly during the early postoperative period in the MS group (P < 0.05). Compared with the early postoperative period, LAD further reduced, and the EF increased significantly during the mid-term post-operation (P<0.05). The LAD reduced significantly during the early postoperative period in the MI group (P < 0.05), together with relatively decreased EF (P < 0.05). Compared with the early postoperative period, LAD further reduced, and the EF increased significantly during the mid-term post-operation (P<0.05). The improvement of LAD in the MI group during the mid-term post-operation was better than that in the MS group (P < 0.05).

Conclusion

The cardioversion effects and the improvement in cardiac function during the mid-term post-operation were good in the radiofrequency ablation by intracardiac operation under direct vision in patients with different mitral valve diseases combined with AF. The cardioversion effects during the early postoperative period and the mid-term post-operation were better in patients with MI than in those with MS.