1
|
Amin AM, Nawlo A, Ibrahim AA, Hassan A, Saber A, Abuelazm M, Abdelazeem B. Efficacy and safety of radiofrequency ablation versus cryoballoon ablation for persistent atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials. Egypt Heart J 2024; 76:89. [PMID: 38976090 PMCID: PMC11231113 DOI: 10.1186/s43044-024-00518-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND Persistent Atrial Fibrillation (PeAF) is a challenging case for rhythm control modalities. Catheter ablation is the mainstay in PeAF management; however, data regarding the comparative safety and efficacy of cryoballoon ablation (CBA) versus radiofrequency ablation (RFA) for PeAF is still limited. We aim to compare the safety and efficacy of CBA versus RFA for PeAF ablation. METHODS We conducted a systematic review and meta-analysis synthesizing randomized controlled trials (RCTs), which were retrieved by systematically searching PubMed, EMBASE, Web of Science, SCOPUS, and Cochrane through October 2023. RevMan version 5.4 software was used to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI). PROSPERO ID CRD42023480314. RESULTS Three RCTs with 400 patients were included. There was no significant difference between RFA and CBA regarding AF recurrence (RR: 0.77, 95% CI [0.50, 1.20], P = 0.25), atrial tachycardia or atrial flutter recurrence (RR: 0.54, 95% CI [0.11, 2.76], P = 0.46), and any arrhythmia recurrence (RR: 0.96, 95% CI [0.70, 1.31], P = 0.80). CBA was significantly associated with decreased total procedure duration (MD: - 45.34, 95% CI [- 62.68, - 28.00], P < 0.00001), with no significant difference in fluoroscopy duration (MD: 3.59, 95% CI [- 5.13, 12.31], P = 0.42). Safety parameters were similar in both groups, including the incidence of any complications, phrenic nerve palsy (RR: 2.91 with 95% CI [0.31, 27.54], P = 0.35), access site complications (RR: 0.33 with 95% CI [0.05, 2.03], P = 0.23), and pericardial effusion. CONCLUSIONS In PeAF catheter ablation, CBA is comparable to RFA in terms of safety and efficacy. Also, CBA is associated with a shorter total procedure duration.
Collapse
Affiliation(s)
| | - Ahmad Nawlo
- Division of Infectious Diseases, Brigham and Women's Hospital- Harvard Medical School, Boston, MA, 02115, USA
| | - Ahmed A Ibrahim
- Faculty of Medicine, Menoufia University, Saad Zaghloul St., Shibin El-Kom, 32511, Menoufia Governorate, Egypt.
| | - Ahmed Hassan
- Faculty of Medicine, October 6 University, Giza, Egypt
- Department of Cardiology, Suez Medical Complex, Ministry of Health and Population, Suez, Egypt
| | | | | | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, Morgantown, WV, USA
| |
Collapse
|
2
|
Liu D, Li Y, Zhao Q. Effects of Inflammatory Cell Death Caused by Catheter Ablation on Atrial Fibrillation. J Inflamm Res 2023; 16:3491-3508. [PMID: 37608882 PMCID: PMC10441646 DOI: 10.2147/jir.s422002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023] Open
Abstract
Atrial fibrillation (AF) poses a serious healthcare burden on society due to its high morbidity and the resulting serious complications such as thrombosis and heart failure. The principle of catheter ablation is to achieve electrical isolation by linear destruction of cardiac tissue, which makes AF a curable disease. Currently, catheter ablation does not have a high long-term success rate. The current academic consensus is that inflammation and fibrosis are central mechanisms in the progression of AF. However, artificially caused inflammatory cell death by catheter ablation may have a significant impact on structural and electrical remodeling, which may affect the long-term prognosis. This review first focused on the inflammatory response induced by apoptosis, necrosis, necroptosis, pyroptosis, ferroptosis and their interaction with arrhythmia. Then, we compared the differences in cell death induced by radiofrequency ablation, cryoballoon ablation and pulsed-field ablation. Finally, we discussed the structural and electrical remodeling caused by inflammation and the association between inflammation and the recurrence of AF after catheter ablation. Collectively, pulsed-field ablation will be a revolutionary innovation with faster, safer, better tissue selectivity and less inflammatory response induced by apoptosis-dominated cell death.
Collapse
Affiliation(s)
- Dishiwen Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, People’s Republic of China
- Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, People’s Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan, 430060, People’s Republic of China
| | - Yajia Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, People’s Republic of China
- Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, People’s Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan, 430060, People’s Republic of China
| | - Qingyan Zhao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, People’s Republic of China
- Cardiovascular Research Institute, Wuhan University, Wuhan, 430060, People’s Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan, 430060, People’s Republic of China
| |
Collapse
|
3
|
Cryoballoon ablation of persistent atrial fibrillation for de novo pulmonary vein isolation: a single-center follow-up study. J Geriatr Cardiol 2022; 19:725-733. [PMID: 36338279 PMCID: PMC9618841 DOI: 10.11909/j.issn.1671-5411.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Pulmonary vein isolation (PVI) alone for persistent atrial fibrillation (PersAF) remains controversial. The characteristics of cryoballoon ablation (CBA) to treat PersAF and the blanking period recurrence are underreported. METHODS This study retrospectively analyzed patients with PersAF undergoing second-generation CBA for de novo PVI. The post-procedural efficacy and survival analysis were compared between patients with different PersAF durations. The multivariate Cox regression analysis was used to detect the risk factors for recurrence. Early and long-term recurrence were analyzed relative to each other. RESULTS A total of 329 patients were enrolled, with a median PersAF duration of 4.0 months (interquartile range: 2.0-12.0 months); 257 patients (78.1%) were male. Kaplan-Meier analysis of freedom from atrial fibrillation recurrence at 12, 24, and 30 months showed 71.0%, 58.5%, and 54.9%, respectively. Early PersAF had a relatively favorable survival rate and a narrow P-wave duration of restoring sinus rhythm compared with that of PersAF lasting more than three months (P < 0.05). The multivariate Cox regression analysis revealed that PersAF duration and left atrial anteroposterior diameter ≥ 42 mm were the risk factors for atrial fibrillation recurrence after CBA [hazard ratio (HR) = 1.89, 95% CI: 1.01-1.4, P = 0.042; HR = 3.6, 95% CI: 2.4-5.4, P < 0.001, respectively]. The blanking period recurrence predicted the long-term recurrence (P < 0.0001). CONCLUSIONS CBA of PersAF had safety and efficacy to reach de novo PVI. The PersAF duration and left atrial size were risk factors for atrial fibrillation recurrence after CBA. Blanking period recurrence was associated with long-term recurrence.
Collapse
|
4
|
Cryoballoon Ablation versus Radiofrequency Ablation in Patients with Persistent Atrial Fibrillation (CRRF-PeAF): Protocol for a Prospective, Multicenter, Randomized, Controlled Study. IJC HEART & VASCULATURE 2022; 41:101074. [PMID: 35782707 PMCID: PMC9241129 DOI: 10.1016/j.ijcha.2022.101074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 11/23/2022]
|
5
|
Cecchini F, Mugnai G, Iacopino S, Abugattas JP, Adriaenssens B, Al-Housari M, Almorad A, Bala G, Bisignani A, de Asmundis C, De Greef Y, Maj R, Osòrio TG, Pannone L, Schwagten B, Sieira J, Sorgente A, Stroker E, Wolf M, Chierchia GB. Safety and long-term efficacy of cryoballoon ablation for atrial fibrillation in octogenarians: a multicenter experience. J Interv Card Electrophysiol 2022; 65:559-571. [DOI: 10.1007/s10840-022-01313-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/18/2022] [Indexed: 11/28/2022]
|
6
|
Linear lesions for treating the recurrence of persistent atrial tachyarrhythmia after cryoballoon ablation of atrial fibrillation. Arch Cardiovasc Dis 2022; 115:252-263. [DOI: 10.1016/j.acvd.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/25/2021] [Accepted: 02/07/2022] [Indexed: 11/18/2022]
|
7
|
Kobori A, Sasaki Y, Pak M, Ishikura M, Murai R, Okada T, Toyota T, Taniguchi T, Kim K, Ehara N, Kinoshita M, Kihara Y, Furukawa Y. Comparison of Cryoballoon and Contact Force-Sensing Radiofrequency Ablation for Persistent Atrial Fibrillation in Clinical Practice. Circ J 2022; 86:290-298. [PMID: 34565782 DOI: 10.1253/circj.cj-21-0608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Outcomes of cryoballoon ablation for persistent atrial fibrillation (AF) are unclear, especially in Japanese patients, so the effectiveness and safety of cryoballoon ablation in clinical practice were retrospectively compared with those of contact force-sensing radiofrequency (CFRF) ablation including the high-power protocol. METHODS AND RESULTS Consecutive patients with persistent AF were reviewed, and 253 and 265 patients who underwent cryoballoon and CFRF ablation, respectively, were enrolled. The primary endpoint was atrial arrhythmia recurrence. The secondary endpoints were periprocedural complications and repeat ablation. The rate of additional left atrial (LA) ablation after pulmonary vein isolation (PVI) was similar between groups (68.8% cryoballoon vs. 74.0% CFRF, P=0.19). Freedom from atrial arrhythmia recurrence was comparable between groups over a follow-up of 25.5±12.5 months (72.3% cryoballoon vs. 69.8% CFRF; adjusted hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.59-1.21, P=0.36). Outcomes were similar in the subgroups of PVI alone and PVI plus additional LA ablation. LA posterior wall isolation, absence of defragmentation, and low creatine clearance, but not catheter selection, were associated with the primary endpoint. Periprocedural complications (adjusted HR 0.73, 95% CI 0.34-1.54, P=0.41) and repeat ablation (adjusted HR 1.11, 95% CI 0.71-1.74, P=0.64) were similar for both procedures. CONCLUSIONS Cryoballoon ablation for persistent AF in Japanese clinical practice had acceptable outcomes comparable to those of advanced CFRF ablation.
Collapse
Affiliation(s)
- Atsushi Kobori
- Department of Cardiology, Kobe City Medical Center General Hospital
| | - Yasuhiro Sasaki
- Department of Cardiology, Kobe City Medical Center General Hospital
| | - Misun Pak
- Department of Cardiology, Kobe City Medical Center General Hospital
| | | | - Ryosuke Murai
- Department of Cardiology, Kobe City Medical Center General Hospital
| | - Taiji Okada
- Department of Cardiology, Kobe City Medical Center General Hospital
| | - Toshiaki Toyota
- Department of Cardiology, Kobe City Medical Center General Hospital
| | | | - Kitae Kim
- Department of Cardiology, Kobe City Medical Center General Hospital
| | - Natsuhiko Ehara
- Department of Cardiology, Kobe City Medical Center General Hospital
| | - Makoto Kinoshita
- Department of Cardiology, Kobe City Medical Center General Hospital
| | - Yasuki Kihara
- Department of Cardiology, Kobe City Medical Center General Hospital
| | - Yutaka Furukawa
- Department of Cardiology, Kobe City Medical Center General Hospital
| |
Collapse
|
8
|
Chen L, Chen JQ, Zou T, Chen Q, Lian LH, Yang ZP, Wu MQ, Lin YZ, Peng YM, Lin W, Liao XW, Huang QL, Zhang JC. Efficacy of extended antrum ablation based on substrate mapping plus pulmonary vein isolation in the treatment of atrial fibrillation. Rev Port Cardiol 2022; 41:17-26. [DOI: 10.1016/j.repc.2021.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/25/2022] Open
|
9
|
Miyazaki S, Sekihara T, Hasegawa K, Mukai M, Aoyama D, Nodera M, Tada H. The feasibility and safety of substrate modification on the left atrial roof area using a cryoballoon in atrial fibrillation ablation. Int J Cardiol 2021; 350:41-47. [PMID: 34954279 DOI: 10.1016/j.ijcard.2021.12.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 11/27/2021] [Accepted: 12/20/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data on additional substrate modification using a cryoballoon beyond cryoballoon pulmonary vein isolation (CB-PVI) is limited. We sought to evaluate the efficacy and safety of substrate modification on the left atrial roof area using CBs (LAR-CBs) for atrial fibrillation (AF) patients. METHODS Eighty-one AF patients (70.0[62.5-77.0] years, 33 paroxysmal AF[PAF], 48 non-PAF) underwent LAR-CBs following CB-PVIs. Voltage maps were created with a high-resolution mapping system. Roof line conduction block was evaluated during the repeat procedure. RESULTS The total number of applications for the CB-PVI and LAR-CB were 5.0 ± 1.2 and 3.8 ± 0.7, and both were significantly greater in non-PAF than PAF patients. LA roof areas had continuous scar in 61/79(77.2%) patients, and the mean balloon temperature was significantly lower in patients with continuous scar than those without (-39.3 ± 3.8 vs. 36.0 ± 4.6 °C, p = 0.004). The single procedure 1-year AF freedom was 87.6% (7.5% on antiarrhythmic drug) and was similar between PAF and non-PAF patients (p = 0.14). Twelve (14.8%) patients underwent a second procedure 5.5(2.2-7.5) months later, and a mean of 1.3 ± 0.5 PVs were reconnected in 7/12(58.3%) patients. Electrical conduction block across the roof line was proven in 3/12(25.0%) patients. There were 6(7.4%) complications related to the procedures, including iatrogenic roof dependent atrial tachycardia, takotsubo cardiomyopathy, and severe pericarditis in 1, 1, and 2 patients, respectively. CONCLUSIONS LA roof area substrate modification using CBs yielded a high arrhythmia freedom after single procedures. However, a low incidence of electrical conduction block across the line during the chronic phase and delayed complications were the major concerns.
Collapse
Affiliation(s)
- Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.
| | - Takayuki Sekihara
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Kanae Hasegawa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Moe Mukai
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Daisetsu Aoyama
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Minoru Nodera
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| |
Collapse
|
10
|
Shi LB, Rossvoll O, Tande P, Schuster P, Solheim E, Chen J. Cryoballoon vs. radiofrequency catheter ablation: insights from NOrwegian randomized study of PERSistent Atrial Fibrillation (NO-PERSAF study). Europace 2021; 24:226-233. [PMID: 35134151 PMCID: PMC8824490 DOI: 10.1093/europace/euab281] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/28/2021] [Indexed: 11/23/2022] Open
Abstract
Aims Pulmonary vein isolation (PVI) is still regarded as a cornerstone for treatment of persistent atrial fibrillation (AF). This study evaluated the effectiveness of PVI performed with cryoballoon ablation (CBA) in comparison with radiofrequency ablation (RFA) in patients with persistent AF. Methods and results A total of 101 patients with symptomatic persistent AF were enrolled and randomized (1:1) to CBA or RFA groups and followed up for 12 months. The primary endpoint was any documented recurrent atrial tachyarrhythmia (ATA) lasting longer than 30 s following a 3-month blanking period. Secondary endpoints were procedure-related complications, procedure and ablation duration, and fluoroscopy time. The ATA-free survival curves were estimated by Kaplan–Meier method and analysed by the log-rank test. According to intention-to-treat analysis, freedom from ATA was achieved in 36 out of 52 patients in the CBA group and 30 out of 49 patients in the RFA group (69.2% vs. 61.2%, P = 0.393). No difference in AF recurrence was found between the two groups (27.5% in CBA vs. 38.0% in RFA, P = 0.258), and less atrial flutter recurrence was documented in the CBA group compared with the RFA group (3.9% vs. 18.0%, P = 0.020). The procedure and ablation duration were significantly shorter in the CBA group (160 ± 31 vs. 197 ± 38 min, P < 0.0001; 36.7 ± 9.5 vs. 55.3 ± 16.7 min, P < 0.0001). There was no difference regarding fluoroscopy time (21.5 ± 7.8 vs. 23.4 ± 11.2 min, P > 0.05). Conclusion Compared with RFA, PVI performed by CBA led to shorter procedure and ablation duration, with less atrial flutter recurrence and similar freedom from ATA at 12-month follow-up.
Collapse
Affiliation(s)
- Li-Bin Shi
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Jonas Lies vei 65, N-5021 Bergen, Norway
| | - Ole Rossvoll
- Department of Cardiology, St. Olav’s Hospital, Trondheim, Norway
| | - Pål Tande
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway
| | - Peter Schuster
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Jonas Lies vei 65, N-5021 Bergen, Norway
| | - Eivind Solheim
- Department of Heart Disease, Haukeland University Hospital, Jonas Lies vei 65, N-5021 Bergen, Norway
| | - Jian Chen
- Corresponding author. Tel: +47 55 972220; fax: +47 55 975150. E-mail address:
| |
Collapse
|
11
|
Results and Predictive Factors After One Cryoablation for Persistent Atrial Fibrillation. Am J Cardiol 2021; 159:65-71. [PMID: 34481590 DOI: 10.1016/j.amjcard.2021.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 11/21/2022]
Abstract
Cryoballoon pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF) ablation is an increasingly used strategy. We aimed to determine the results and predictors of arrhythmia recurrence after a single procedure of cryoballoon PVI for patients with persistent and long-standing persistent AF. We included all consecutive patients who underwent cryoballoon PVI for the treatment of persistent symptomatic drug-refractory AF since 2012. All patients were prospectively followed to detect the recurrence of atrial tachyarrhythmia (ATa). Predictors of recurrence were assessed. Cryoballoon PVI was performed on 399 patients with persistent AF, among whom 52 (13%) had long-standing persistent AF. Patients with long-standing persistent AF had a significantly larger left atrium than those with persistent AF. A 28-mm cryoballoon was used for 322 patients (93%). In total, 359 patients (90%) completed the 12-month follow-up visit and the median follow-up was 24 months (interquartile range 43 to 13). The 2-year probability of freedom from ATa recurrence was 51% for persistent AF and 27% for long-standing persistent AF. Long-standing persistent AF and left atrial area/volume were independent predictors of ATa recurrence. Ten patients (2.5%) experienced phrenic nerve palsy, 1 tamponade (0.25%), 2 stroke (0.5%), 2 pericardial effusions (0.5%), and 5 vascular complications (1.25%). In conclusion, 2-year ATa-free survival rates were 51 and 27% for persistent and long-standing persistent AF patients, respectively. Complications were rare. Long-standing persistent AF and left-atrial area/volume were predictors of recurrence.
Collapse
|
12
|
Miyazaki S, Hasegawa K, Mukai M, Aoyama D, Nodera M, Uzui H, Tada H. Cryoballoon left atrial roof ablation for persistent atrial fibrillation ∼Analysis with high-resolution mapping system∼. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 45:589-597. [PMID: 34427933 DOI: 10.1111/pace.14345] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/12/2021] [Accepted: 08/08/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Additional benefit of cryoballoon left atrial roof line ablation (CB-RA) beyond cryoballoon pulmonary vein isolation (CB-PVI) is suggested in patients with persistent atrial fibrillation (PsAF). We sought to investigate the feasibility of CB-RA for PsAF and to determine the ablation area. METHODS AND RESULTS Fifty-three PsAF patients (67[58.5-75.5] years, 36 men, 11 longstanding PsAF) underwent CB-PVI. Subsequently, 44(83.0%) out of 53 patients underwent additional CB-RA. Voltage maps were created in all patients with a high-resolution mapping system. The total number and duration of CB-RAs were 3.9±0.7 and 468±84 seconds. LA roof areas were complete low voltage areas (LVAs) /scar in 37/44(84.1%) patients ("complete roof modification"). The normal LA posterior wall (LAPW) voltage area was 6.1(4.1-8.4)cm2, and the %LAPW isolation area was 61.0(47.2-71.7)%. The %LAPW isolation area was significantly greater in CB-RA patients than those without (64.0[54.2-73.2] vs. 45.0[39.5-50.5]%, p = 0.041) despite significantly larger LAs in the former group. The %LAPW isolation area was significantly greater in patients with transverse LA diameters <45 mm than those ≥45 mm (p<0.0001). The single procedure 1-year AF freedom was 87.4% (22.5% on antiarrhythmic drug) and tended to be higher in CB-RA patients than those without. Among the 44 CB-RA patients, it was significantly higher in patients with a complete roof modification than those without (94.4% vs. 75.0%, p = 0.0049). One CB-RA patient experienced a delayed cardiac tamponade requiring drainage at 4-months post-procedure. CONCLUSIONS CB-RA significantly expanded the LAPW isolation area, and a complete roof modification resulted in a high arrhythmia freedom in PsAF patients. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Kanae Hasegawa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Moe Mukai
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Daisetsu Aoyama
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Minoru Nodera
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hiroyasu Uzui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| |
Collapse
|
13
|
Schmidt B, Brugada J, Arbelo E, Laroche C, Bayramova S, Bertini M, Letsas KP, Pison L, Romanov A, Scherr D, Tilz RR, Maggioni A, Adragao P, Lund J, Haman L, Oliveira MM, Dagres N. Ablation strategies for different types of atrial fibrillation in Europe: results of the ESC-EORP EHRA Atrial Fibrillation Ablation Long-Term registry. Europace 2021; 22:558-566. [PMID: 31821488 DOI: 10.1093/europace/euz318] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 11/29/2019] [Indexed: 12/12/2022] Open
Abstract
AIMS The ESC EORP EHRA Atrial Fibrillation (AF) Ablation Long-Term registry was designed to assess management and outcomes of AF catheter ablation procedures in Europe. To investigate the current ablation approaches and their outcomes for patients with paroxymal AF (PAF) and non-PAF in Europe. METHODS AND RESULTS Data from index ablations were collected in 27 European countries at 104 centres in a prospective fashion. Pre-procedural, procedural, and 1-year follow-up data were captured on a web-based electronic case record form. Data on the ablation procedure were available for 3446 patients. Of these, 2513 patients and 933 patients underwent pulmonary vein isolation (PVI) or PVI plus (PVIplus) additional ablation, respectively. The ablation strategy was limited to PVI in 81% and 56% of patients in the PAF and non-PAF group, respectively (P < 0.001). In the non-PAF group, left atrial linear ablation and ablation of complex fragmented atrial electrograms were more commonly performed. Arrhythmias recurrence after PVI was 29% and 39% in the PAF and non-PAF group, respectively (P < 0.001) and 42% after PVIplus in both groups. Atrial fibrillation related hospital admissions were more common in the PVIplus group (20% vs. 14%). A very low procedural complication rate was observed. No relevant differences were observed with regard to repeat ablation (PVI 9% and PVIplus 11%). CONCLUSION In patients with PAF and non-PAF, the ablation strategies of PVI and PVIplus led to similar arrhythmia-free survival rates after 1 year. A considerable hospital readmission rate was noted.
Collapse
Affiliation(s)
- Boris Schmidt
- Cardioangiologisches Centrum Bethanien, AGAPLESION Markus Krankenhaus, Wilhelm-Epstein Str. 4, 60431 Frankfurt, Germany
| | - Josep Brugada
- Pediatric Arrhythmia Unit, Cardiovascular Institute, Hospital Clínic, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Elena Arbelo
- Department of Cardiology, Cardiovascular Institute, Hospital Clinic de Barcelona, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain.,Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Cécile Laroche
- EURObservational Research Programme, EORP, European Society of Cardiology, Sophia-Antipolis, France
| | - Sevda Bayramova
- E. Meshalkin National Medical Research Center» of the Ministry of Health of the Russian Federation, Rechkunovskaya, Novosibirsk, Russia
| | | | | | - Laurent Pison
- Cardiology, Ziekenhuis Oost Limburg, Schiepse Bos 6, 3600 Genk, Belgium
| | - Alexander Romanov
- E. Meshalkin National Medical Research Center» of the Ministry of Health of the Russian Federation, Rechkunovskaya, Novosibirsk, Russia
| | | | - Roland Richard Tilz
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Luebeck, Medical Clinic II, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Luebeck, Germany.,Department II. Med. Kardiologie, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Aldo Maggioni
- EURObservational Research Programme, EORP, European Society of Cardiology, Sophia-Antipolis, France.,ANMCO Research Center, Florence, Italy
| | | | - Juha Lund
- Turku University Hospital, Turku, Finland
| | - Ludek Haman
- University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | | | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | |
Collapse
|
14
|
La Rosa G, Quintanilla JG, Salgado R, González-Ferrer JJ, Cañadas-Godoy V, Pérez-Villacastín J, Jalife J, Pérez-Castellano N, Filgueiras-Rama D. Anatomical targets and expected outcomes of catheter-based ablation of atrial fibrillation in 2020. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:341-359. [PMID: 33283883 DOI: 10.1111/pace.14140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/18/2020] [Accepted: 11/29/2020] [Indexed: 11/29/2022]
Abstract
Anatomical-based approaches, targeting either pulmonary vein isolation (PVI) or additional extra PV regions, represent the most commonly used ablation treatments in symptomatic patients with atrial fibrillation (AF) recurrences despite antiarrhythmic drug therapy. PVI remains the main anatomical target during catheter-based AF ablation, with the aid of new technological advances as contact force monitoring to increase safety and effective radiofrequency (RF) lesions. Nowadays, cryoballoon ablation has also achieved the same level of scientific evidence in patients with paroxysmal AF undergoing PVI. In parallel, electrical isolation of extra PV targets has progressively increased, which is associated with a steady increase in complex cases undergoing ablation. Several atrial regions as the left atrial posterior wall, the vein of Marshall, the left atrial appendage, or the coronary sinus have been described in different series as locations potentially involved in AF initiation and maintenance. Targeting these regions may be challenging using conventional point-by-point RF delivery, which has opened new opportunities for coadjuvant alternatives as balloon ablation or selective ethanol injection. Although more extensive ablation may increase intraprocedural AF termination and freedom from arrhythmias during the follow-up, some of the targets to achieve such outcomes are not exempt of potential severe complications. Here, we review and discuss current anatomical approaches and the main ablation technologies to target atrial regions associated with AF initiation and maintenance.
Collapse
Affiliation(s)
- Giulio La Rosa
- Department of Myocardial Pathophysiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain
| | - Jorge G Quintanilla
- Department of Myocardial Pathophysiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ricardo Salgado
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain
| | - Juan José González-Ferrer
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Victoria Cañadas-Godoy
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Julián Pérez-Villacastín
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - José Jalife
- Department of Myocardial Pathophysiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Nicasio Pérez-Castellano
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - David Filgueiras-Rama
- Department of Myocardial Pathophysiology, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| |
Collapse
|
15
|
Ikenouchi T, Inaba O, Takamiya T, Inamura Y, Sato A, Matsumura Y, Sato H, Hirakawa A, Takahashi Y, Goya M, Sasano T, Nitta J. The impact of left atrium size on selection of the pulmonary vein isolation method for atrial fibrillation: Cryoballoon or radiofrequency catheter ablation. Am Heart J 2021; 231:82-92. [PMID: 33098808 DOI: 10.1016/j.ahj.2020.10.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/15/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the cornerstone of ablation strategies for atrial fibrillation (AF), and noninferiority of cryoballoon (CB) over radiofrequency (RF) ablation has been previously reported. One of the risk factors of recurrence is left atrium (LA) enlargement. This study aimed to analyze the impact of LA enlargement on the selection of CB or RF ablation for AF patients. METHODS A total of 2,224 AF patients (64.4 ± 10.7 years, 65.5% male) who underwent PVI were analyzed retrospectively. Left atrial diameter (LAD) and volume (LAV) were measured using echocardiography before the procedures. LA enlargement was defined as LAD ≥40 mm and LAV index (LAVI) ≥35 mL/m2. Patients undergoing CB and RF ablation were propensity score matched, and 376 matched pairs were evaluated. RESULTS Cox proportional hazard analysis revealed that LAD (95% CI, 1.01-1.05), LAV (95% CI, 1.01-1.02), and LAVI (95% CI, 1.01-1.03) were independent predictors of recurrence. CB showed equivalent clinical outcomes to those of RF with shorter procedure time required for patients without LA enlargement. CB was inferior to RF in patients with LA enlargement (LAD, 74.5% vs 84.6%, P = .028; LAVI, 74.7% vs 83.4%, P = .015), and large LAVI was associated with a higher prevalence of non-PV foci (35% vs 29%, P = .008). CONCLUSIONS CB ablation may be recommended for patients without enlarged LA based on the short procedure time and efficacy, whereas RF would be more appropriate in large LAs. LAVI may be a valuable reference to predict PVI outcomes and in selecting the ablation method.
Collapse
Affiliation(s)
- Takashi Ikenouchi
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-ku, Saitama City, Saitama, Japan.
| | - Osamu Inaba
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-ku, Saitama City, Saitama, Japan
| | - Tomomasa Takamiya
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-ku, Saitama City, Saitama, Japan
| | - Yukihiro Inamura
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-ku, Saitama City, Saitama, Japan
| | - Akira Sato
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-ku, Saitama City, Saitama, Japan
| | - Yutaka Matsumura
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-ku, Saitama City, Saitama, Japan
| | - Hiroyuki Sato
- Division of Biostatistics and Data Science, Clinical Research Center, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Akihiro Hirakawa
- Division of Biostatistics and Data Science, Clinical Research Center, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Yoshihide Takahashi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Junichi Nitta
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahicho, Fuchu-shi, Tokyo, Japan
| |
Collapse
|
16
|
Yorgun H, Canpolat U, Okşul M, Şener YZ, Ateş AH, Crijns HJGM, Aytemir K. Long-term outcomes of cryoballoon-based left atrial appendage isolation in addition to pulmonary vein isolation in persistent atrial fibrillation. Europace 2020; 21:1653-1662. [PMID: 31504432 DOI: 10.1093/europace/euz232] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/29/2019] [Indexed: 11/13/2022] Open
Abstract
AIMS Pulmonary vein isolation (PVI) alone in persistent atrial fibrillation (AF) is not as successful as in paroxysmal AF, and recent data indicate the key role of non-PV triggers. We aimed to assess the long-term safety and efficacy of left atrial appendage isolation (LAAi) as an adjunct to PVI using cryoballoon (CB) in persistent AF. METHODS AND RESULTS We compared 144 persistent AF patients (59 ± 10 years, 51% females) who underwent PVI combined with LAAi with a propensity-score matched cohort of 138 persistent AF patients (59 ± 6 years, 52% female) in whom PVI-only was performed. Baseline and follow-up data including electrocardiography (ECG), 24-h Holter ECG's, and echocardiography were recorded for all patients. Atrial tachyarrhythmia (ATa) recurrence was defined as detection of AF, atrial flutter, or atrial tachycardia (≥30 s) after a 3-month blanking period. At a mean of 30.5 ± 5.6 months follow-up, 85 (61.6%) patients in the PVI-only group and 109 (75.7%) patients in the PVI+LAAi group were free of ATa after the index procedure (P = 0.008). Ischaemic stroke/transient ischaemic attack was detected in 4 (2.9%) patients in PVI-only group and in 5 (3.5%) patients in the PVI+LAAi group (P = 0.784). Cox regression analysis revealed that the PVI-only strategy was found as a significant predictor for recurrence (hazard ratio 3.01, 95% confidence interval 1.81-5.03; P < 0.001). CONCLUSIONS Our findings indicated that CB-based LAAi+PVI was associated with a favourable efficacy compared to PVI-only strategy in patients with persistent AF. Although ischaemic event rates were similar between the groups, rigorous adherence to anticoagulation regime is paramount in order to prevent thrombo-embolic complications.
Collapse
Affiliation(s)
- Hikmet Yorgun
- Faculty of Medicine, Department of Cardiology, Hacettepe University, Sıhhıye,Ankara, Turkey.,Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Uğur Canpolat
- Faculty of Medicine, Department of Cardiology, Hacettepe University, Sıhhıye,Ankara, Turkey
| | - Metin Okşul
- Faculty of Medicine, Department of Cardiology, Hacettepe University, Sıhhıye,Ankara, Turkey
| | - Yusuf Ziya Şener
- Faculty of Medicine, Department of Cardiology, Hacettepe University, Sıhhıye,Ankara, Turkey
| | - Ahmet Hakan Ateş
- Faculty of Medicine, Department of Cardiology, Hacettepe University, Sıhhıye,Ankara, Turkey
| | - Harry J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kudret Aytemir
- Faculty of Medicine, Department of Cardiology, Hacettepe University, Sıhhıye,Ankara, Turkey
| |
Collapse
|
17
|
Yakabe D, Aso A, Araki M, Murasato Y, Nakamura T. Efficacy of hybrid therapy using prior administration of bepridil hydrochloride and cryoballoon ablation in patients with persistent atrial fibrillation. J Cardiol 2020; 75:360-367. [DOI: 10.1016/j.jjcc.2019.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/31/2019] [Accepted: 08/20/2019] [Indexed: 10/26/2022]
|
18
|
The effect of second-generation cryoablation without electrical mapping in persistent AF using continuous monitoring. J Interv Card Electrophysiol 2020; 60:175-182. [PMID: 32147799 DOI: 10.1007/s10840-020-00721-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/24/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Second-generation cryoballoon ablation is safe and effective in patients with persistent atrial fibrillation (AF). The aim of this study is to report the real long-term AF burden and freedom from AF post-cryoablation using continuous monitoring, and to assess whether intraoperative confirmation of pulmonary vein isolation using electrical mapping is necessary. METHODS A total of 33 patients (mean age 75.7 ± 5.6 years, 16 men) with persistent AF who underwent second-generation cryoablation without electrical mapping were reviewed. All patients had a cardiac implantable device and were followed up for a mean of 755 ± 170 days. RESULTS AF burden significantly decreased from 67.51% ± 34.90% to 18.28% ± 26.65% at 1-year follow-up, and this reduction was maintained at final follow-up (18.26% ± 23.70%, p < 0.001). Continuous monitoring revealed a freedom from AF rate of 33% and 24% at 1-year and full follow-up, respectively. Patients who remained in persistent AF at final follow-up had a trend towards higher pre-ablation AF burden (81.6% ± 29.7% vs 57.3% ± 36.4%, p = 0.08). CONCLUSION Second-generation cryoablation without confirming pulmonary vein isolation using electrical mapping is effective leading to significant reductions in AF burden based on continuous beat-to-beat monitoring at 1-year and long-term follow-up.
Collapse
|
19
|
Maclean E, Yap J, Saberwal B, Kolvekar S, Lim W, Wijesuriya N, Papageorgiou N, Dhillon G, Hunter R, Lowe M, Lambiase P, Chow A, Abbas H, Schilling R, Rowland E, Ahsan S. The convergent procedure versus catheter ablation alone in longstanding persistent atrial fibrillation: A single centre, propensity-matched cohort study. Int J Cardiol 2020; 303:49-53. [DOI: 10.1016/j.ijcard.2019.10.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/15/2019] [Accepted: 10/31/2019] [Indexed: 12/11/2022]
|
20
|
The influence of iatrogenic atrial septal defect on the prognosis of patients with atrial fibrillation between cryoablation and radiofrequency ablation. Biosci Rep 2020; 40:221856. [PMID: 31930391 PMCID: PMC7007401 DOI: 10.1042/bsr20193128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/22/2019] [Accepted: 12/31/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The present study was to compare the incidence of septal defect (SD) in patients with atrial fibrillation (AF) who received radiofrequency ablation or cryoablation. METHODS A total of 293 AF patients were performed with radiofrequency ablation and cryoablation. Cardiac ultrasonography was performed to calculate left atrial diameter (LAD), left atrial ejection fraction (LAEF%), strain rate (SR), left ventricular systolic (SRs), left ventricular diastolic (SRe), and left atrial systole (SRa) before surgery, 3 months and 1 year after surgery. The patients were followed up to observe statin and angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) medication, AF recurrence, 6-min walk test, stroke, any symptoms caused by arrhythmia, and re-hospitalization. RESULTS The levels of LAD and SD were higher, while SRe and SRa were lower in the cryoablation group in the comparison with the radiofrequency ablation group after surgery (P<0.05). LAEF was lower in the cryoablation group than the radiofrequency ablation group after 3 months (P<0.05). After 1-year follow-up, no right-to-left shunt occurred in all patients with SD. The AF recurrence rate in SD group was higher than that in the normal group (P<0.05). The use of statin and the application of ACEI/ARB were protective factors, whereas hypertension, LAD, left atrial operation time, and surgical plan were risk factors. CONCLUSION SD affects left atrial function and increases the risk of AF recurrence. Hypertension, LAD, and left atrial operation time are risk factors for SD, whereas statin and ACEI/ARB drugs can reduce SD.
Collapse
|
21
|
Terricabras M, Verma A. Is pulmonary vein isolation enough for persistent atrial fibrillation? J Cardiovasc Electrophysiol 2020; 31:2148-2153. [PMID: 32022320 DOI: 10.1111/jce.14381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 02/02/2020] [Indexed: 11/28/2022]
Abstract
Pulmonary vein isolation (PVI) is a well-established treatment for atrial fibrillation (AF); however, studies report suboptimal outcomes in persistent AF. Adjuvant ablation targeting the substrate outside the pulmonary veins has been proposed to improve the success rates of the procedure. In this review, we summarize the current evidence regarding additional ablation over PVI in persistent AF. We describe the different approaches for adjuvant ablation, outcomes, and future perspectives.
Collapse
Affiliation(s)
- Maria Terricabras
- Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada
| |
Collapse
|
22
|
Yorgun H, Canpolat U, Gümeler E, Okşul M, Şener YZ, Ateş AH, Akkaya F, Karahan S, Hazırolan T, Aytemir K. Immediate and long-term outcomes of cryoballoon catheter ablation in patients with atrial fibrillation and left common pulmonary vein anatomy. J Interv Card Electrophysiol 2019; 59:57-65. [PMID: 31811460 DOI: 10.1007/s10840-019-00676-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 11/25/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The efficacy of cryoballoon (CB) for atrial fibrillation (AF) ablation is still debatable in case of anatomical variations like left common pulmonary vein (LCPV). We aimed to assess the impact of LCPV trunk on the acute and long-term clinical outcomes in patients with CB based AF ablation. METHODS We compared a total of 82 AF patients (62.5% paroxysmal and 37.5% persistent) who underwent pulmonary vein isolation using CB (LCPV+ group) with a propensity score-matched cohort of 76 AF patients (LCPV- group) (61.8% paroxysmal and 38.2% persistent). Preprocedural computed tomography was performed in all patients and ostial dimensions and trunk distance were measured. Atrial tachyarrhythmia (ATa) recurrence was defined as detection of AF, atrial flutter, or atrial tachycardia (≥ 30 s) after a 3-month blanking period. RESULTS Acute procedural success was similar between the groups (100% and 98.7% for LCPV- and LCPV+, respectively, P = 0.991). Overall, 22/76 (28.9%) patients in LCPV- and 21/82 (25.6%) patients in LCPV+ had ATa recurrence at a mean follow-up of 31 ± 15 months (P = 0.770). A multivariate analysis identified only the left atrial (LA) diameter as a predictor of recurrent ATs (HR, 3.28; 95% CI, 1.67-6.41; P = 0.001). In the LCPV+ group, patients with single application had higher ATa recurrence (8/18 patients) compared with sequential freeze group (13/64 patients) (P = 0.042). CONCLUSIONS Our findings indicated that CB was an effective tool in patients with LCPV and freedom from ATa was similar between LCPV- and LCPV+ groups. Only LA diameter predicted the ATa recurrence during long-term follow-up.
Collapse
Affiliation(s)
- Hikmet Yorgun
- Department of Cardiology, Faculty of Medicine, Hacettepe University, 06230, Sıhhıye, Ankara, Turkey. .,Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Uğur Canpolat
- Department of Cardiology, Faculty of Medicine, Hacettepe University, 06230, Sıhhıye, Ankara, Turkey
| | - Ekim Gümeler
- Department of Radiology, Faculty of Medicine, Hacettepe University Ankara, Ankara, Turkey
| | - Metin Okşul
- Department of Cardiology, Faculty of Medicine, Hacettepe University, 06230, Sıhhıye, Ankara, Turkey
| | - Yusuf Ziya Şener
- Department of Cardiology, Faculty of Medicine, Hacettepe University, 06230, Sıhhıye, Ankara, Turkey
| | - Ahmet Hakan Ateş
- Department of Cardiology, Faculty of Medicine, Hacettepe University, 06230, Sıhhıye, Ankara, Turkey
| | - Fatih Akkaya
- Department of Cardiology, Faculty of Medicine, Hacettepe University, 06230, Sıhhıye, Ankara, Turkey
| | - Sevilay Karahan
- Department of Biostatistics, Faculty of Medicine, Hacettepe University Ankara, Ankara, Turkey
| | - Tuncay Hazırolan
- Department of Radiology, Faculty of Medicine, Hacettepe University Ankara, Ankara, Turkey
| | - Kudret Aytemir
- Department of Cardiology, Faculty of Medicine, Hacettepe University, 06230, Sıhhıye, Ankara, Turkey
| |
Collapse
|
23
|
Chun JKR, Bordignon S, Chen S, Tohoku S, Bologna F, Urbanek L, Schmidt BH. Current Status of Atrial Fibrillation Ablation with Balloon Strategy. Korean Circ J 2019; 49:991-1001. [PMID: 31646768 PMCID: PMC6813157 DOI: 10.4070/kcj.2019.0226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/18/2019] [Indexed: 01/09/2023] Open
Abstract
Catheter ablation of atrial fibrillation (AF) has been established worldwide and is recommended for symptomatic paroxysmal AF patients according to international guidelines. Importantly, the cornerstone of any AF ablation represents pulmonary vein isolation (PVI). Traditional radiofrequency (RF) point by point ablation within a 3D electroanatomic left atrial (LA) map requires profound understanding of LA anatomy and electrophysiology. This ablation strategy can be highly efficient and safe if performed in experienced hands and centers. However, procedural complexity causes a long learning curve and has limited its wide spread utilization. In contrast, balloon based PVI ablation strategies are based on an anatomic principle. Currently, two balloon types (cryoballoon and laserballoon) have been adopted to clinical routine. Both balloons are positioned at the target PV and circumferential energy ablation is enabled. This simplified anatomic approach facilitates reaching the procedural endpoint of PVI and demonstrated less operator dependency. Therefore, balloon PVI appears to be associated with improved procedural reproducibility and safety. Importantly, large scale randomized trials proved non-inferiority of balloon guided AF ablation (cryothermal and laser energy) vs. experienced operators using traditional “gold standard” RF ablation in paroxysmal and persistent AF. Ongoing technological refinements of both balloons as well as the introduction of novel energy dosing strategies and ablation targets may potentially impact the current way of ablating AF in future. This review will summarize current clinical experience of contemporary balloon devices and will look into future developments.
Collapse
Affiliation(s)
- Julian Kyoung Ryul Chun
- Medizinische Klinik III, CCB Kardiologie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany.
| | - Stefano Bordignon
- Medizinische Klinik III, CCB Kardiologie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Shaojie Chen
- Medizinische Klinik III, CCB Kardiologie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Shota Tohoku
- Medizinische Klinik III, CCB Kardiologie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Fabrizio Bologna
- Medizinische Klinik III, CCB Kardiologie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Lukas Urbanek
- Medizinische Klinik III, CCB Kardiologie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Boris Heinrich Schmidt
- Medizinische Klinik III, CCB Kardiologie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| |
Collapse
|
24
|
Akkaya E, Berkowitsch A, Rieth A, Erkapic D, Hamm CW, Neumann T, Kuniss M. Clinical outcome and left atrial function after left atrial roof ablation using the cryoballoon technique in patients with symptomatic persistent atrial fibrillation. Int J Cardiol 2019; 292:112-118. [DOI: 10.1016/j.ijcard.2019.04.091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/16/2019] [Accepted: 04/29/2019] [Indexed: 12/15/2022]
|
25
|
Shahabi J, Emkanjoo Z, Haghjoo M, Alizadeh A, Fazelifar A, Madadi S, Kamali F, Sharifi M, Karimian Z, Yadegarfar G. Cryoballoon ablation results and complications in mid-term follow-up of patients with atrial fibrillation. ARYA ATHEROSCLEROSIS 2019; 14:272-275. [PMID: 31143228 PMCID: PMC6527147 DOI: 10.22122/arya.v14i6.1772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common cardiac arrhythmia, and its prevalence increases with advancing age. Pulmonary vein isolation is a standard approach in drug refractory paroxysmal AF which could be performed by cryoballoon ablation (CBA). We tried to evaluate its efficacy and safety in Iranian patients with AF. METHODS From 2015 to 2017, 97 patients with paroxysmal and persistent AF were enrolled in our observational historical cohort study. They were visited 1 and 6 months post-procedure in order to assess the efficacy (recurrence) and safety. Recurrence was defined as 30 seconds of arrhythmia on their 48-hours Holter monitoring. RESULTS Ninety-seven patients enrolled in the study, 64 (66.0%) of them were men, and their mean age was 55 ± 12 years. Hypertension was reported in 41 patients (42.3%), as the most common cardiac risk factor. 71 patients (73.2%) patients with paroxysmal AF and 15 patients (15.5%) with persistent AF underwent the procedure. After 6 months, recurrence was documented in only 17 patients (17.5%), and 82.5% of the patients were free from the recurrence. Post-procedural complication was detected only in 3 patients (3.1%). CONCLUSION In our study, the mid-term success and safety of CBA in patients with paroxysmal AF was showed. CBA is a safe and effective method in paroxysmal AF, and even in some cases with persistent AF.
Collapse
Affiliation(s)
- Javad Shahabi
- Assistant Professor, Heart Failure Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Emkanjoo
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Majid Haghjoo
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Abolfath Alizadeh
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Amirfarjam Fazelifar
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Shabnam Madadi
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Farzad Kamali
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mehrana Sharifi
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Karimian
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ghasem Yadegarfar
- Heart Failure Research Center, Cardiovascular Research Institute AND School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
26
|
Koektuerk B, Koektuerk O, Yorgun H, Guelker JE, Turan C, Gorr E, Turan G, Horlitz M, Bansmann PM. Long-term impact of a bonus freeze on clinical outcome: Analysis of effective and non-effective bonus freezes in cryoballoon ablation. PLoS One 2019; 14:e0214231. [PMID: 31050677 PMCID: PMC6499416 DOI: 10.1371/journal.pone.0214231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 03/08/2019] [Indexed: 11/21/2022] Open
Abstract
Purpose Data on bonus freeze characteristics and their impact on complication rates and long-term clinical outcome are limited. Methods Pulmonary vein isolation (PVI) using a 28 mm 2nd-generation cryoballoon (CB) was performed in 169 patients (pts). The isolation temperatures, time to isolation and minimal temperatures of the cryoapplications were documented. Results The study included 92 pts who received one bonus freeze after PVI in group I and 77 pts who did not receive a bonus freeze in group II. After a mean follow-up time of 19.0±8.6 months in group I and 16.4±7.5 months in group II, 67 of 92 pts (72.8%) and 49 of 75 pts available to follow up (65.3%; p = 0.221) were free of atrial tachyarrhythmia, respectively. Phrenic nerve palsy occurred in 5.4% of the pts in group I (5/92 pts) and 1.3% of the pts in group II (1/77 pts; p = 0.22). Both the mean nadir temperatures of the bonus freezes and mean nadir temperatures of the isolation freezes differed significantly between the recurrent and non-recurrent pts in group I. The predilection sites of the reconduction for both groups were the inferior aspect of the inferior pulmonary veins. Conclusion The impact of a bonus freeze on long-term clinical outcome was not significant for two reasons: 1) The necessity of a bonus freeze was low because the long-term clinical success rate without a bonus freeze was high; and 2) the majority of bonus freezes, especially at the predilection sites, such as the inferior PV, appeared to be ineffective.
Collapse
Affiliation(s)
- Buelent Koektuerk
- Witten/Herdecke University, Helios Dr. Horst Schmidt Kliniken Wiesbaden, Clinic for invasive Electrophysiology and Rhythmology/ Division Cardiology II, Wiesbaden, Germany
- * E-mail:
| | - Oezlem Koektuerk
- Witten/Herdecke University, Department of Medicine, Witten, Germany
| | - Hikmet Yorgun
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Jan-Erik Guelker
- Heart Centre Niederrhein, Department of Cardiology, Helios Clinic Krefeld, Krefeld, Germany
| | - Cem Turan
- Witten/Herdecke University, Krankenhaus Porz am Rhein, Department of Cardiology / Electrophysiology, Cologne, Germany
| | - Eduard Gorr
- Witten/Herdecke University, Krankenhaus Porz am Rhein, Department of Cardiology / Electrophysiology, Cologne, Germany
| | - Goekmen Turan
- Witten/Herdecke University, Krankenhaus Porz am Rhein, Department of Cardiology / Electrophysiology, Cologne, Germany
| | - Marc Horlitz
- Witten/Herdecke University, Krankenhaus Porz am Rhein, Department of Cardiology / Electrophysiology, Cologne, Germany
| | - Paul Martin Bansmann
- Witten/Herdecke University, Krankenhaus Porz am Rhein, Department of Radiology, Cologne, Germany
| |
Collapse
|
27
|
Bavishi AA, Kaplan RM, Peigh G, Diaz CL, Baman JR, Trivedi A, Wasserlauf J, Shen MJ, Sattayaprasert P, Chicos AB, Kim S, Verma N, Arora R, Lin A, Knight BP, Passman RS. Patient characteristics as predictors of recurrence of atrial fibrillation following cryoballoon ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:694-704. [PMID: 30912155 DOI: 10.1111/pace.13669] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/27/2019] [Accepted: 03/20/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND While several studies have evaluated predictors for atrial fibrillation (AF) recurrence following catheter ablation, there are limited data specific to cryoballoon ablation (CBA). METHODS We analyzed a prospective registry of patients at a single institution who underwent CBA. Recurrence of AF (RAF) was defined as recurrence of AF by 12-month follow-up, excluding the 3-month blanking period. Univariate analysis was performed to evaluate predictors of RAF. Receiver operating characteristic analysis was used to compare and evaluate the performance of various risk scores for discriminating risk of RAF. RESULTS There were 542 patients included in the analysis with mean age 61.3 ± 10.6 years, 67.9% male, and 51.6% paroxysmal AF (PAF). Overall, only left atrial diameter (LAD) > 40 mm and ERAF (early recurrence of AF within 0-3 month blanking period) were significant predictors of RAF. In the PAF specific subgroup, LAD > 40 mm, AF duration > 12 months, prior stroke or transient ischemic attack, ERAF, and having previously failed an antiarrhythmic drug were significant predictors of RAF. In persistent AF (PeAF) subgroup, obstructive sleep apnea (OSA) and ERAF were significant predictors of RAF. Out of clinical risk scores tested, BASEAF2 had the highest performance with area under the curve of 0.646 (95% confidence interval [0.548, 0.708]; P < .01). CONCLUSIONS In this single-center retrospective study of CBA, we found only LAD > 40 mm and ERAF to be predictors of RAF. We identified OSA as a potential targetable risk factor in PeAF patients undergoing CBA. Out of risk scores tested for discriminating risk of RAF, BASEAF2 had the best performance.
Collapse
Affiliation(s)
- Aakash A Bavishi
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rachel M Kaplan
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,The Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | - Graham Peigh
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Celso L Diaz
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jayson R Baman
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Amar Trivedi
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,The Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | - Jeremiah Wasserlauf
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,The Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | - Mark J Shen
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,The Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | - Prasongchai Sattayaprasert
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,The Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | - Alexandru B Chicos
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,The Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | - Susan Kim
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,The Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | - Nishant Verma
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,The Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | - Rishi Arora
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,The Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | - Albert Lin
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,The Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | - Bradley P Knight
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,The Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | - Rod S Passman
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,The Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| |
Collapse
|
28
|
A Review of the Use of Cryoballoon Ablation for the Treatment of Persistent Atrial Fibrillation. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0605-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
29
|
Radiofrequency Catheter Ablation Versus Cryoballoon Ablation in the Treatment of Paroxysmal Atrial Fibrillation: A Cost-effectiveness Analysis in China. Clin Ther 2019; 41:78-91. [DOI: 10.1016/j.clinthera.2018.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 11/13/2018] [Accepted: 11/14/2018] [Indexed: 11/21/2022]
|
30
|
Takarada K, Ströker E, de Asmundis C, Sieira J, Abugattas JP, Coutiño HE, Salghetti F, Choudhury R, Iacopino S, Brugada P, Chierchia GB. Second-Generation Cryoballoon Ablation for Atrial Fibrillation ― A Detailed Analysis of the Impact of Left Atrial Volume Index on Clinical Outcome ―. Circ J 2018; 83:84-90. [DOI: 10.1253/circj.cj-18-0650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Affiliation(s)
- Ken Takarada
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel
| | - Erwin Ströker
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel
| | - Juan Sieira
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel
| | - Juan-Pablo Abugattas
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel
| | - Hugo-Enrique Coutiño
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel
| | - Francesca Salghetti
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel
| | - Rajin Choudhury
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel
| | | | - Pedro Brugada
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel
| |
Collapse
|
31
|
Abstract
PURPOSE OF REVIEW Although radiofrequency-based pulmonary vein isolation (PVI) was considered the 'gold standard' for the treatment of atrial fibrillation for a long time, the cryoballoon has turned out to be a common alternative tool for atrial fibrillation ablation. Most of the data regarding cryoballoon-based ablation relate to patients with paroxysmal atrial fibrillation (PAF). In this review, we summarize recent knowledge on the usage of cryoballoon ablation for other conditions, especially persistent atrial fibrillation. RECENT FINDINGS The cryoballoon is an effective ablation tool for PVI. As PVI is the first-line recommended procedural endpoint in atrial fibrillation ablation, it can be recommended not only for the treatment of PAF but also persistent atrial fibrillation and results in satisfying clinical outcomes. Recently, smaller studies and case reports were published reporting on cryoballoon ablation strategies beyond stand-alone PVI. These studies report a wide application spectrum of the cryoballoon and therefore potentially increase clinical success as well as the patient collective amenable to cryoballoon ablation. SUMMARY Cryoballoon-based PVI can be recommended not only for patients with PAF but also for patients with persistent atrial fibrillation. Ablation strategies going beyond PVI need further evaluation, but might expand the use of the cryoballoon.
Collapse
|
32
|
Ciconte G, Coulombe N, Brugada P, de Asmundis C, Chierchia GB. Towards a tailored cryo-pulmonary vein isolation. Lessons learned from second-generation cryoballoon ablation. Trends Cardiovasc Med 2018; 29:420-425. [PMID: 30552043 DOI: 10.1016/j.tcm.2018.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 10/30/2018] [Accepted: 11/12/2018] [Indexed: 01/08/2023]
Abstract
Second-generation cryoballoon ablation has emerged as an effective and practical approach for the treatment of atrial fibrillation. It gained the overall interest of the electrophysiology community due to its excellent success rates, and reproducible clinical outcomes comparable to the point-by-point radiofrequency technique. This technology offers several advantages including a fast learning curve and shorter procedure times making this device widely adopted in many EP-laboratories as an alternative strategy to conventional point-by-point radiofrequency ablation. As compared to its predecessor, the improved technical performances of the second-generation cryoballoon translated into favorable clinical outcomes, which are maintained in long-term follow-up. However, the ideal cryo-application duration and the adequate number of freeze-thaw cycles are not well established and predictors of durable electrical isolation are poorly known. This review provides some practical advices for a successful ablation using the second-generation cryoballoon.
Collapse
Affiliation(s)
- Giuseppe Ciconte
- Arrhythmia and Electrophysiology Center, IRCCS Policlinico San Donato, San Donato Milanese, Milano, Italy.
| | | | - Pedro Brugada
- Heart Rhythm Management Centre, UZ Brussel-VUB, Brussels, Belgium
| | | | | |
Collapse
|
33
|
Clinical outcome of the 2nd generation cryoballoon for pulmonary vein isolation in patients with persistent atrial fibrillation - A sub-study of the randomized trial evaluating single versus dual cryoballoon applications. Int J Cardiol 2018; 278:120-125. [PMID: 30409738 DOI: 10.1016/j.ijcard.2018.10.097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/24/2018] [Accepted: 10/26/2018] [Indexed: 11/20/2022]
Abstract
AIMS To assess the efficacy of the 2nd generation Cryoballoon for pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (PersAF), and to compare it to patients with paroxysmal atrial fibrillation (PAF). METHODS The outcome (arrhythmia recurrence at 12 months) was prospectively assessed in patients with PersAF(n = 77) and compared to that in patients with PAF(n = 62), who underwent PVI within a randomized trial evaluating single versus dual applications with the 2nd generation cryoballoon. Other endpoints included symptoms of AF, quality of life, procedure related characteristics, redo ablation rates and adverse events. Variables predicting recurrences were studied including all patients. RESULTS Freedom from arrhythmia recurrence was 64.9% after a single ablation and 68.8% after one or more procedures, which was significantly lower compared to PAF patients; 82.2% (p = 0.029) and 83.9% (p = 0.048) respectively, at 12 months. The improvements in EHRA score (-1.3 ± 0.8, p < 0.0001), symptom severity score (SSQ) (-5.0 ± 4.2, p < 0.0001) and EQ5D-5 L global score (+10.4 ± 20.3, p = 0.0002) after ablation was significant compared to baseline. The re-ablation rate was 7/77 (9.1%) which did not differ from that in PAF patients, 9/62 (14.5%), p = 0.42. Procedure duration, 104.8 ± 37.4 versus 113 ± 31.2 min (p = 0.129), application time, 1605 ± 659 versus 1521 ± 557 s (p = 0.103) and total adverse events after 12 months, 8/77 (10.4%) versus 5/62 (8.1%) (p = 0.77) did not differ in PersAF versus PAF patients. CONCLUSION Both symptoms and QoL improved significantly in patients with PersAF after ablation. Freedom from AF was clinically significant but lower than in PAF patients. The cryoballoon seems an effective technique also in patients with persistent AF.
Collapse
|
34
|
Boveda S, Metzner A, Nguyen DQ, Chun KRJ, Goehl K, Noelker G, Deharo JC, Andrikopoulos G, Dahme T, Lellouche N, Defaye P. Single-Procedure Outcomes and Quality-of-Life Improvement 12 Months Post-Cryoballoon Ablation in Persistent Atrial Fibrillation: Results From the Multicenter CRYO4PERSISTENT AF Trial. JACC Clin Electrophysiol 2018; 4:1440-1447. [PMID: 30466850 DOI: 10.1016/j.jacep.2018.07.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/05/2018] [Accepted: 07/19/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The CRYO4PERSISTENT AF (Cryoballoon Ablation for Early Persistent Atrial Fibrillation) trial aims to report long-term outcomes after a single pulmonary vein isolation (PVI)-only ablation procedure using the second-generation cryoballoon in persistent atrial fibrillation (PerAF) patients. BACKGROUND Pulmonary vein isolation is recognized as the cornerstone of atrial fibrillation (AF) ablation, including ablation of PerAF. METHODS The CRYO4PERSISTENT AF trial (NCT02213731) is a prospective, multicenter, single-arm trial designed to assess single-procedure outcomes of PVI using the cryoballoon. The primary endpoint was freedom from AF, atrial flutter, or atrial tachycardia ≥30 s after a 90-day blanking period. After enrollment, but before ablation, patients without 100% AF burden (18-h Holter monitoring or 3 consecutive electrocardiograms in a time frame ≥14 days) were excluded. Patients were followed at 3, 6, and 12 months, with 48-h Holter monitoring at 6 and 12 months. Quality of life and symptoms were evaluated at baseline and 12 months. Arrhythmia recurrence and adverse events were adjudicated by an independent committee. RESULTS A total of 101 patients (62 ± 11 years of age, 74% men, left ventricular ejection fraction 56 ± 8%, left atrial diameter 43 ± 5 mm) meeting criteria, undergoing cryoballoon-based PVI, with follow-up data, were included. Kaplan-Meier estimate of freedom from AF, atrial flutter, or atrial tachycardia recurrence was 60.7% at 12 months. Compared with baseline, there were significantly fewer patients with arrhythmia-related symptoms at 12 months (16% vs. 92%; p < 0.0001). The symptom reduction was supported by significant improvement in 36-Item Short Form Health Survey composite scores and European Heart Rhythm Association score at 12 months. The only device related event was transient phrenic nerve injury in 2 (2%) patients, with resolution pre-discharge. CONCLUSIONS Cryoballoon ablation for treatment of PerAF demonstrated 61% single-procedure success at 12 months post-ablation in addition to significant reduction in arrhythmia-related symptoms and improved quality of life. (Cryoballoon Ablation for Early Persistent Atrial Fibrillation [Cryo4 Persistent AF]; NCT02213731).
Collapse
Affiliation(s)
| | | | | | - K R Julian Chun
- Markuskrankenhaus, Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | | | - Georg Noelker
- Clinic for Cardiology Herz- und Diabeteszentrum North Rhine-Westphalia Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | | | | | | | | | - Pascal Defaye
- Centre Hospitalier Universitaire de Grenoble-Alpes, Grenoble, France
| |
Collapse
|
35
|
Chen S, Schmidt B, Bordignon S, Bologna F, Perrotta L, Nagase T, Chun KRJ. Atrial fibrillation ablation using cryoballoon technology: Recent advances and practical techniques. J Cardiovasc Electrophysiol 2018; 29:932-943. [PMID: 29663562 DOI: 10.1111/jce.13607] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 02/12/2018] [Accepted: 03/12/2018] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation (AF) affects 1-2% of the population, and its prevalence is estimated to double in the next 50 years as the population ages. AF results in impaired patients' life quality, deteriorated cardiac function, and even increased mortality. Antiarrhythmic drugs frequently fail to restore sinus rhythm. Catheter ablation is a valuable treatment approach for AF, even as a first-line therapy strategy in selected patients. Effective electrical pulmonary vein isolation (PVI) is the cornerstone of all AF ablation strategies. Use of radiofrequency (RF) catheter in combination of a three-dimensional electroanatomical mapping system is the most established ablation approach. However, catheter ablation of AF is challenging even sometimes for experienced operators. To facilitate catheter ablation of AF without compromising the durability of the pulmonary vein isolation, "single shot" ablation devices have been developed; of them, cryoballoon ablation, is by far the most widely investigated. In this report, we review the current knowledge of AF and discuss the recent evidence in catheter ablation of AF, particularly cryoballoon ablation. Moreover, we review relevant data from the literature as well as our own experience and summarize the key procedural practical techniques in PVI using cryoballoon technology, aiming to shorten the learning curve of the ablation technique and to contribute further to reduction of the disease burden.
Collapse
Affiliation(s)
- Shaojie Chen
- CCB, Cardioangiologisches Centrum Bethanien Frankfurt am Main, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Boris Schmidt
- CCB, Cardioangiologisches Centrum Bethanien Frankfurt am Main, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Stefano Bordignon
- CCB, Cardioangiologisches Centrum Bethanien Frankfurt am Main, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Fabrizio Bologna
- CCB, Cardioangiologisches Centrum Bethanien Frankfurt am Main, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Laura Perrotta
- CCB, Cardioangiologisches Centrum Bethanien Frankfurt am Main, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Takahiko Nagase
- CCB, Cardioangiologisches Centrum Bethanien Frankfurt am Main, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - K R Julian Chun
- CCB, Cardioangiologisches Centrum Bethanien Frankfurt am Main, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| |
Collapse
|
36
|
Approaches to Catheter Ablation of Nonparoxysmal Atrial Fibrillation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:39. [DOI: 10.1007/s11936-018-0632-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
37
|
Yorgun H, Canpolat U, Kocyigit D, Çöteli C, Evranos B, Aytemir K. Left atrial appendage isolation in addition to pulmonary vein isolation in persistent atrial fibrillation: one-year clinical outcome after cryoballoon-based ablation. Europace 2018; 19:758-768. [PMID: 28340073 DOI: 10.1093/europace/eux005] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 01/18/2017] [Indexed: 11/14/2022] Open
Abstract
Aims In this study, we sought to evaluate the safety and efficacy of cryoballoon (CB) based empirical left atrial appendage (LAA) isolation as an adjunct to pulmonary vein isolation (PVI) compared to the PVI-only strategy in patients with persistent AF. Objectives Clinical outcomes of catheter ablation were less beneficial for persistent atrial fibrillation (AF) than paroxysmal AF. Methods and results A total of 100 consecutive patients with persistent AF underwent both PVI and additional LAA isolation using CB (Group II). As a control group (Group I), among persistent AF patients, we conducted a retrospective, propensity-score matched cohort, in whom only PVI was performed using CB. Recurrence of atrial tachyarrhythmia (Ata) at the 12th month follow-up was the primary endpoint. Baseline demographic and clinical characteristics were similar between two groups. At the 12th month follow-up, 67 (67%) patients in Group I and 86 (86%) patients in Group II were free of ATa after the index procedure (P < 0.001). As a unique complication of LAA isolation, left circumflex artery spasm was observed in 4% of the Group II. After adjusting for several baseline variables, PVI-only strategy was found as a significant predictor for recurrence (HR: 3.37; 95% CI: 1.73-6.56; P < 0.001). Transoesophageal echocardiography examination during the follow-up revealed no thrombus in the LAA. Conclusion Our findings indicated that LAA isolation as an adjunct to PVI improved 1-year outcomes in persistent AF compared with the PVI-only strategy using CB without an increase in thromboembolic complications.
Collapse
|
38
|
Safety and efficacy of persistent atrial fibrillation ablation using the second-generation cryoballoon. Clin Res Cardiol 2018; 107:570-577. [PMID: 29492703 DOI: 10.1007/s00392-018-1219-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 02/19/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The second-generation cryoballoon (CB) is increasingly used for treatment of persistent atrial fibrillation (AF). Data regarding the clinical outcome and mechanism of arrhythmia recurrence following persistent AF ablation using CB is sparse. In this study, we aimed to assess the efficacy of CB and mechanisms of atrial tachyarrhythmia (ATA) recurrence in patients with persistent AF. METHODS AND RESULTS A total of 133 patients (66 ± 10 years, 60% male) with symptomatic persistent AF, who were scheduled for PVI using the second-generation CB were enrolled. Follow-up included 24 h Holter recording at 3, 6 and 12 months. Any documented episode of ATA lasting more than 30 s was considered as a recurrent arrhythmic event. All targeted veins were isolated (100%). Phrenic nerve palsy with recovery during follow-up occurred in six patients (4.5%), no patient experienced tamponade or a cerebrovascular event. During 12.6 ± 5.4 months of follow-up, 89/133 (67%) patients were free of ATA recurrences. Multivariable analysis revealed recurrence in the blanking period (HR 11.46, 0.95 CI 3.92-33.49, p < 0.001), presence of cardiomyopathy (HR 2.75, 0.95 CI 1.09-6.96, p = 0.032) and PV abnormality (HR 3.56, 0.95 CI 1.21-10.43, p = 0.021) as predictors for late recurrence. CONCLUSION In patients with persistent AF, second-generation cryoballoon use is associated with an excellent safety profile and favorable outcomes. Arrhythmia recurrence during the blanking period, presence of cardiomyopathy and PV abnormality were independent predictors of long-term AF recurrence.
Collapse
|
39
|
Voskoboinik A, Moskovitch JT, Harel N, Sanders P, Kistler PM, Kalman JM. Revisiting pulmonary vein isolation alone for persistent atrial fibrillation: A systematic review and meta-analysis. Heart Rhythm 2018; 14:661-667. [PMID: 28434446 DOI: 10.1016/j.hrthm.2017.01.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Indexed: 10/19/2022]
Abstract
BACKGROUND Early studies demonstrated relatively low success rates for pulmonary vein isolation (PVI) alone in patients with persistent atrial fibrillation (PeAF). However, the advent of new technologies and the observation that additional substrate ablation does not improve outcomes have created a new focus on PVI alone for treatment of PeAF. OBJECTIVE The purpose of this study was to systematically review the recent medical literature to determine current medium-term outcomes when a PVI-only approach is used for PeAF. METHODS An electronic database search (MEDLINE, Embase, Web of Science, PubMed, Cochrane) was performed in August 2016. Only studies of PeAF patients undergoing a "PVI only" ablation strategy using contemporary radiofrequency (RF) technology or second-generation cryoballoon (CB2) were included. A random-effects model was used to assess the primary outcome of pooled single-procedure 12-month arrhythmia-free survival. Predictors of recurrence were also examined and a meta-analysis performed if ≥4 studies examined the parameter. RESULTS Fourteen studies of 956 patients, of whom 45.2% underwent PVI only with RF and 54.8% with CB2, were included. Pooled single-procedure 12-month arrhythmia-free survival was 66.7% (95% confidence interval [CI] 60.8%-72.2%), with the majority of patients (80.5%) off antiarrhythmic drugs. Complication rates were very low, with cardiac tamponade occurring in 5 patients (0.6%) and persistent phrenic nerve palsy in 5 CB2 patients (0.9% of CB2). Blanking period recurrence (hazard ratio 4.68, 95% CI 1.70-12.9) was the only significant predictor of recurrence. CONCLUSION A PVI-only strategy in PeAF patients with a low prevalence of structural heart disease using contemporary technology yields excellent outcomes comparable to those for paroxysmal AF ablation.
Collapse
Affiliation(s)
- Aleksandr Voskoboinik
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Baker IDI Heart & Diabetes Institute, Melbourne, Australia; Heart Centre, Alfred Hospital, Melbourne, Australia
| | | | - Nadav Harel
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Peter M Kistler
- Baker IDI Heart & Diabetes Institute, Melbourne, Australia; Heart Centre, Alfred Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia.
| |
Collapse
|
40
|
Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Cosedis Nielsen J, Curtis AB, Davies DW, Day JD, d’Avila A, (Natasja) de Groot NMS, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2018; 20:e1-e160. [PMID: 29016840 PMCID: PMC5834122 DOI: 10.1093/europace/eux274] [Citation(s) in RCA: 727] [Impact Index Per Article: 121.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Hugh Calkins
- From the Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research Center, Milan, Italy)
| | | | - Eduardo B Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George's University of London, London, United Kingdom
| | | | | | | | | | | | - D Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
| | | | | |
Collapse
|
41
|
Laser Balloon or Wide-Area Circumferential Irrigated Radiofrequency Ablation for Persistent Atrial Fibrillation. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005767. [DOI: 10.1161/circep.117.005767] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 11/08/2017] [Indexed: 11/16/2022]
|
42
|
Akkaya E, Berkowitsch A, Zaltsberg S, Greiss H, Hamm CW, Sperzel J, Neumann T, Kuniss M. Second-generation cryoballoon ablation for treatment of persistent atrial fibrillation: Three-year outcome and predictors of recurrence after a single procedure. J Cardiovasc Electrophysiol 2017; 29:38-45. [DOI: 10.1111/jce.13372] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 10/05/2017] [Accepted: 10/11/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Ersan Akkaya
- Department of Cardiology; Kerckhoff Heart Center; Bad Nauheim Germany
| | | | - Sergej Zaltsberg
- Department of Cardiology; Kerckhoff Heart Center; Bad Nauheim Germany
| | - Harald Greiss
- Department of Cardiology; Kerckhoff Heart Center; Bad Nauheim Germany
| | - Christian W. Hamm
- Department of Cardiology; Kerckhoff Heart Center; Bad Nauheim Germany
- Med. Clinic I; Justus-Liebig University; Giessen Germany
| | - Johannes Sperzel
- Department of Cardiology; Kerckhoff Heart Center; Bad Nauheim Germany
| | - Thomas Neumann
- Department of Cardiology; Kerckhoff Heart Center; Bad Nauheim Germany
| | - Malte Kuniss
- Department of Cardiology; Kerckhoff Heart Center; Bad Nauheim Germany
| |
Collapse
|
43
|
Saini A, Huizar JF, Tan A, Koneru JN, Ellenbogen KA, Kaszala K. Scar Homogenization in Atrial Fibrillation Ablation: Evolution and Practice. J Atr Fibrillation 2017; 10:1645. [PMID: 29250241 DOI: 10.4022/jafib.1645] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 07/19/2017] [Accepted: 09/14/2017] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation (AF) ablation has emerged as the preferred rhythm control strategy for symptomatic paroxysmal AF refractory or intolerant to at least one class I or III antiarrhythmic medication. Since the initial observation by Haissaguerre and colleagues, of pulmonary vein triggers initiating atrial fibrillation (AF), pulmonary vein isolation (PVI) has become the cornerstone for paroxysmal AF ablation therapy.
Collapse
Affiliation(s)
- Aditya Saini
- Division of Cardiology, Hunter Holmes McGuire VAMC and Virginia Commonwealth University, Richmond, VA
| | - Jose F Huizar
- Division of Cardiology, Hunter Holmes McGuire VAMC and Virginia Commonwealth University, Richmond, VA
| | - Alex Tan
- Division of Cardiology, Hunter Holmes McGuire VAMC and Virginia Commonwealth University, Richmond, VA
| | - Jayanthi N Koneru
- Division of Cardiology, Hunter Holmes McGuire VAMC and Virginia Commonwealth University, Richmond, VA
| | - Kenneth A Ellenbogen
- Division of Cardiology, Hunter Holmes McGuire VAMC and Virginia Commonwealth University, Richmond, VA
| | - Karoly Kaszala
- Division of Cardiology, Hunter Holmes McGuire VAMC and Virginia Commonwealth University, Richmond, VA
| |
Collapse
|
44
|
Omran H, Gutleben KJ, Molatta S, Fischbach T, Wellmann B, Horstkotte D, Körber B, Nölker G. Second generation cryoballoon ablation for persistent atrial fibrillation: an updated meta-analysis. Clin Res Cardiol 2017; 107:182-192. [PMID: 29075979 DOI: 10.1007/s00392-017-1171-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 10/10/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Catheter ablation is an established treatment option for patients with symptomatic atrial fibrillation (AF). The cornerstone of AF ablation is pulmonary vein isolation (PVI). The second-generation cryoballoon (2G-CB) has shown non-inferiority to radiofrequency (RF) ablation in paroxysmal AF in several trials. Growing evidence suggests that 2G-CB is also effective in patients with persistent AF (perAF). The aim of this study was to summarize and analyze available data on safety and mid-term (≥ 12 months) efficacy of PVI using 2G-CB in patients with perAF. METHODS We did a search in PubMed, Web of Science, Cochrane Library, and clinicaltrials.gov in December 2016 for studies of 2G-CB ablation for perAF. Studies reporting clinical success rates at a follow-up (FU) of ≥ 12 months were included. Success was defined as freedom from any atrial arrhythmia lasting > 30 s after an initial blanking period of 3 months. Acute success and complication rates were also assessed. Data were analyzed applying random-effects model. RESULTS A total of 917 patients from 11 studies meeting study inclusion criteria were analyzed. After a mean FU of 16.7 ± 3.0 months, 68.9% were free from recurrences [95% confidence interval (CI) 63.4-74.7%]. Overall acute success rate was 99.7% (95% CI 99.2-100%). Complications occurred in 5.5% (95% CI 2.4-9.6%). Vascular access complications were the most frequent 3.3% (95% CI 1.5-5.6%). The rate of phrenic nerve palsy/injury was 2.09% (95% CI 0.8-3.9%). No death, stroke or myocardial infarction was reported. CONCLUSION The 2G-CB seems to be safe and effective in the treatment of perAF in the mid-term.
Collapse
Affiliation(s)
- Hazem Omran
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany.
| | - Klaus-Jürgen Gutleben
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Stephan Molatta
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Thomas Fischbach
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Birgit Wellmann
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Dieter Horstkotte
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Britta Körber
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Georg Nölker
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| |
Collapse
|
45
|
Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Nielsen JC, Curtis AB, Davies DW, Day JD, d’Avila A, de Groot N(N, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2017; 14:e275-e444. [PMID: 28506916 PMCID: PMC6019327 DOI: 10.1016/j.hrthm.2017.05.012] [Citation(s) in RCA: 1415] [Impact Index Per Article: 202.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Hugh Calkins
- Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research Center, Milan, Italy)
| | | | - Eduardo B. Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George’s University of London, London, United Kingdom
| | | | | | | | | | | | - D. Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D. Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M. Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M. Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E. Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
| | | | | |
Collapse
|
46
|
WITHDRAWN: 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Arrhythm 2017. [DOI: 10.1016/j.joa.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
47
|
Mugnai G, de Asmundis C, Iacopino S, Stroker E, Longobardi M, De Regibus V, Coutino-Moreno HE, Takarada K, Choudhury R, Abugattas de Torres JP, Storti C, Brugada P, Chierchia GB. Comparison of the Incidences of Complications After Second-Generation Cryoballoon Ablation of Atrial Fibrillation Using Vitamin K Antagonists Versus Novel Oral Anticoagulants. Am J Cardiol 2017; 120:223-229. [PMID: 28532773 DOI: 10.1016/j.amjcard.2017.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/13/2017] [Accepted: 04/13/2017] [Indexed: 12/27/2022]
Abstract
Data evaluating the impact of the periprocedural administration of novel oral anticoagulants (NOACs) on complications in the setting of pulmonary vein (PV) isolation using cryoballoon (CB) is limited. In the present study, our aim was to analyze procedural characteristics and incidence of complications in those patients who underwent CB ablation for atrial fibrillation and the impact of NOACs on adverse events compared with vitamin K antagonists (VKAs). Consecutive patients with drug resistant atrial fibrillation who underwent PV isolation by CB as index procedure were retrospectively included in our analysis. In group I, 290 of 454 patients (63.9%) received VKAs (warfarin: n = 222 and acenocoumarol: n = 68), and in group II, 164 of 454 patients (36.1%) were treated with NOACs (rivaroxaban: n = 71; dabigatran: n = 60; and apixaban: n = 33). Age was significantly higher in the group II (62.8 ± 9.7 vs 58.6 ± 11.3; p <0.001). During the study period, 454 consecutive patients (male 71%, age 60.1 ± 10.9 years) were enrolled. Major complications occurred in 9 patients (2.0%): peripheral vascular complications were observed in 6 patients (1.3% per procedure), persistent phrenic nerve palsy occurred in 2 (0.4%), and transient ischemic attacks in 1 (0.2%). In both groups, the incidence of major complications was similar (group I [VKAs]: 7 patients [2.4%] vs group II [NOACs]: 2 patients [1.2%]; p = 0.5). In conclusion, CB ablation is a safe procedure for PV isolation and is associated with low complication rates. The incidence of adverse events in PV isolation using the second-generation CB with the periprocedural administration of NOACs is not significantly different than VKA treatment.
Collapse
|
48
|
Curnis A, Salghetti F, Cerini M, Vassanelli F, Inama L, Villa C, Giacopelli D, Raweh A, Bontempi L. Efficacy of second-generation cryoballoon ablation in paroxysmal and persistent atrial fibrillation patients. J Cardiovasc Med (Hagerstown) 2017; 18:655-662. [PMID: 28678147 DOI: 10.2459/jcm.0000000000000542] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS In this study, we aimed to compare the efficacy of single pulmonary vein isolation with the second-generation cryoballoon (CB-Adv) and predictors of atrial fibrillation recurrences in patients with paroxysmal (PAF) and persistent atrial fibrillation (PersAF). METHODS Consecutive PAF and PersAF patients undergoing CB-Adv for the first time were enrolled. Patients were followed with in-clinic visits including Holter ECG. Atrial arrhythmic episodes symptomatic or documented lasting more than 30 s were considered as recurrences. RESULTS A total of 96 consecutive patients [77 men (80%), mean age 57.4 ± 9.9 years] were included in this analysis. About 56 (58%) patients had PAF and 40 had (42%) PersAF. The mean procedural and fluoroscopy times were 116 ± 24 and 33 ± 12 min, respectively. Procedure-related complications occurred in four (4.2%) patients.At the 12-month follow-up, after a 3-month blanking period, freedom from recurrences was achieved in 59% [confidence interval (CI): 49-69%] of patients, 62% (CI: 48-75%) in PAF, and 54% (CI: 38-71%) in PersAF group. The difference was not statistically significant at the Kaplan-Meier survival analysis (P = 0.242). Cardioversion to restore sinus rhythm was less frequently needed in PAF group [5% (CI: 1-15%) vs. 25% (CI: 13-41%), P < 0.001]. Redo procedure was performed in 7% (CI: 3-15%) of patients. In the Cox regression analysis, early atrial-tachyarrhythmia recurrence was the only independent predictor of 1-year recurrence (hazard ratio 2.11, CI: 1.06-4.20, P = 0.03). CONCLUSION The success rate at 12 months after a single CB-Adv procedure was 62% in patients with PAF and 54% in study participants with PersAF. Early atrial-tachyarrhythmia recurrence appeared to be the only independent predictor of late atrial fibrillation recurrence.
Collapse
Affiliation(s)
- Antonio Curnis
- aDivision of Cardiology, Spedali Civili Hospital, Brescia bClinical Research, Biotronik Italia, Milan, Italy cCardiac Surgery Department, LUDES University, Lugano, Switzerland
| | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Boveda S. Crioablación de la fibrilación auricular: ¿es útil no solo para la fibrilación auricular paroxística? Rev Esp Cardiol (Engl Ed) 2017. [DOI: 10.1016/j.recesp.2016.09.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
50
|
PIERAGNOLI PAOLO, PAOLETTI PERINI ALESSANDRO, RICCIARDI GIUSEPPE, CHECCHI LUCA, GIOMI ANDREA, MURACA IACOPO, MANNUCCI LETIZIA, PADELETTI LUIGI. Recurrences in the Blanking Period and 12-Month Success Rate by Continuous Cardiac Monitoring After Cryoablation of Paroxysmal and Non-Paroxysmal Atrial Fibrillation. J Cardiovasc Electrophysiol 2017; 28:625-633. [DOI: 10.1111/jce.13190] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 02/09/2017] [Accepted: 02/13/2017] [Indexed: 12/01/2022]
Affiliation(s)
- PAOLO PIERAGNOLI
- Heart and Vessels Department; University of Florence; Florence Italy
| | | | | | - LUCA CHECCHI
- Heart and Vessels Department; University of Florence; Florence Italy
| | - ANDREA GIOMI
- Heart and Vessels Department; University of Florence; Florence Italy
- Ospedale Santa Maria Nuova; Cardiology Unit; Florence Italy
| | - IACOPO MURACA
- Heart and Vessels Department; University of Florence; Florence Italy
| | - LETIZIA MANNUCCI
- Heart and Vessels Department; University of Florence; Florence Italy
| | - LUIGI PADELETTI
- Heart and Vessels Department; University of Florence; Florence Italy
- IRCCS Multimedica; Sesto San Giovanni Milan Italy
| |
Collapse
|