Absence of atrial fibrillation in the blanking period following cryoballoon pulmonary vein isolation – does it always portend a good prognosis?

Background

Cryoballoon (CB) pulmonary vein isolation (PVI) is an accepted method for ablation in patients with paroxysmal and persistent atrial fibrillation (PAF, PeAF). Freedom from AF in the blanking period (BP), conventionally defined as the first 3-months post-PVI, has been associated with the best long-term outcomes. However, the influence of antiarrhythmic drugs (AADs) during the BP on long-term outcomes is not well understood.

Objective

To compare long-term outcomes between patients who were and were not on an AAD prior to ablation and remained free from AF during the 3-month BP post CB PVI.

Methods

We enrolled consecutive AF patients undergoing CB PVI; all pts had an implantable loop recorder (ILR). No patient had any AF in the first 90 days post CB PVI. We divided the patients into three groups: (1) never had exposure to an AAD; (2) were intolerant to/failed AAD and thus were not taking an AAD at time of ablation; and (3) were on AAD at time of ablation. In the latter group, every effort was made to stop the AAD before the end of the BP.

Results

The cohort included 96 pts (66±10 years; 60 [63%] male; 55 [57%] PAF; CHA2DS2-VASc 2.5±1.4). There were 23 (24%) patients in group 1, 13 (14%) patients in group 2, and 60 (63%) pts in group 3. Patients in group 3 were more likely to have PeAF; AADs were stopped at a median of 36 days IQR (27, 91) in this group. Patients were followed for 1-year during which time 28 (29%) patients had recurrent AF (despite having no AF during the BP). The best outcome was seen in patients who never used an AAD; the worst outcome was seen in patients who were on an AAD at time of ablation (Figure 1).

Conclusion

Our data show that absence of AF during a 3-month post CB PVI BP alone does not guarantee good-long term outcome, unless the patient was never treated with an AAD. In contrast, in patients ablated while taking an AAD, recurrent AF was observed in 37% even though they were completely AF-free during the BP.

Funding Acknowledgement

Type of funding sources: None.

Recurrence of atrial fibrillation following pulmonary vein isolation: impact of body mass index on one- and three-year outcomes

Background

Cryoballoon (CB) pulmonary vein isolation (PVI) is an accepted method for ablation in patients with paroxysmal and persistent atrial fibrillation (PAF, PeAF). However, there are a paucity of data about the impact of body mass index (BMI) on one-year and longer-term outcomes following ablation.

Objective

To objectively understand the impact of BMI on outcomes following CB PVI.

Methods

We enrolled consecutive AF patients undergoing CB PVI; all patients had an implantable loop recorder (ILR), which transmitted data wirelessly daily. We assessed AF recurrences after excluding an initial 3-month post-ablation blanking period.

Results

The cohort included 222 pts (66±9 years; 143 [64%] male; 120 [54%] PAF; CHA2DS2-VASc 2.6±1.6). The mean BMI was 30±5. Patients were followed for 763±347 days, during which time 50% and 68% had recurrent AF 1- and 3-years post ablation. We divided the cohort based on the mean BMI into 2 groups: BMI <30 and BMI >30. Heavier patients were younger and more likely to have PeAF. Over 1-year of follow-up, patients with a BMI <30 had similar likelihood of being free of AF to patients with a BMI >30 (46% vs, 56%, p=0.0.097, Figure 1, left). However, as patients were followed for 3-years, freedom from AF was significantly higher in patients with a BMI <30 (59% vs. 81% in BMI >30, p=0.002, Figure 1, right).

Conclusions

Our data show that although patients had similar outcomes 1-year post-ablation, during longer-term follow-up patients with a BMI >30 had a much worse outcome. Our study uniquely offers objective (using an ILR) assessment of the impact of BMI on long-term outcomes following CB PVI (homogenous ablation strategy). These data highlight the need to identify strategies to improve outcomes in obese patients.

Funding Acknowledgement

Type of funding sources: None.

The impact of atrial fibrillation burden early post cryoballoon pulmonary vein isolation on long-term freedom from recurrent atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. A three-month blanking period (BP) is commonly used in clinical trials and practice. Early recurrence of AF portends worse ablation long-term outcome; however, the utility of using AF burden (AFB) early post cryoballoon (CB) PVI to predict long-term outcome is unknown.

Purpose

To determine, using ECG data acquired by an implantable loop recorder (ILR), the relationship between post-ablation AFB and long-term freedom from AF.

Methods

We enrolled consecutive patients with AF who had CB PVI and an ILR. We determined the monthly AFB for the first 3 months post CB PVI and assessed the relationship between AFB and 1-year freedom from AF. We defined 4 distinct AFB groups: (1) 0%, (2) > 0-0.1%, (3) > 0.1-0.5%, and (4) > 0.5%.

Results

There were 210 patients (66 ± 9 years; 138 [66%] male; 116 [55%] paroxysmal AF; CHA2DS2-VASc 2.5 ± 1.6). Following a 3-month BP, 101 (48%) patients had a recurrence of AF at 160 ± 86 days post-ablation. An AFB of > 0% over the first 3 months predicted AF recurrence (p < 0.0001, Figure 1). Patients with > 0.5% AF burden after 1st month and any AF after 2nd month post CB PVI have a very high long-term AF recurrence rate (Figure 2).

Conclusion

The best long term outcome post CB PVI is seen in pts who have no AF in the first 3 months post ablation. An AFB >0.5% after the first month and any AF after the second month portend ablation failure. These data define a clinical utility of using AFB to risk stratify patients post CB PVI.

Yearly incidence and pattern of very late recurrence of atrial fibrillation as detected by continuous electrocardiographic monitoring using an implantable loop recorder

Funding Acknowledgements

Type of funding sources: None.

Background

A very late recurrence (VLR) of atrial fibrillation (AF) is considered present when patients have their first recurrence of AF > 12 months post-ablation. Little is known about the yearly rates and patterns of VLR AF recurrence.

Objective

To assess the yearly incidence and pattern of VLR in pts with AF who underwent cryoballoon (CB) pulmonary vein isolation (PVI).

Methods

We prospectively enrolled consecutive patients with AF who underwent CB PVI and had an implantable loop recorder (ILR) inserted up to 3 months post-ablation. Patients were followed for recurrent AF (excluding a 3-month post-ablation blanking period).

Results

Our cohort included 222 patients (66 ± 9 years; 143 [64%] male; 120 [54%] paroxysmal AF; CHA2DS2-VASc 2.6 ± 1.6). At 1-year, 111 (50%) patients remained free of AF. Two-year follow-up was available in 95 of these patients; 62 (65%) remained in sinus. Three-year follow-up was available in 42 of these patients; 36 (86%) remained in sinus (Figure). Of the 39 patients who developed AF after initially being free of AF for at least 1-year post ablation, 24 (62%) patients had either a frequent or persistent pattern of AF.

Conclusions

Our data show that the greatest likelihood of failure following a CB PVI occurs in the first year of ablation. The rate of failure becomes lower year by year. These data suggest that long term outcome may be driven more by the initial ablation as opposed to progressive evolution of the patient’s substrate

Is there clinical utility to replacement of an implantable loop recorder in patients who have previously undergone cryoballoon pulmonary vein isolation?

Funding Acknowledgements

Type of funding sources: None.

Background

Implantable loop recorders (ILRs) are used for long-term ECG monitoring following catheter ablation in patients (pts) with atrial fibrillation (AF) to guide clinical management. However, little is known about what do when the ILR reaches end of service (EOS).

Purpose

To identify pts who underwent replacement of their ILR and determine the diagnostic yield and clinical utility of the replacement device.

Methods

We enrolled 222 consecutive pts with AF who underwent cryoballoon pulmonary vein isolation (CB PVI) and had an ILR. We identified pts who subsequently underwent ILR replacement. The diagnostic and clinical utility of the newly replaced ILR was determined.

Results

The cohort included 56 pts (64 + 9 years; 35 [63%] male; 27 [48%] PAF; CHA2DS2-VASc 2.3 ± 1.5) in whom the initial ILR reached EOS. They were followed for 3.7 ± 2.1 years. Recurrent AF was observed in 41 (73%) of these pts; this triggered an intervention in 17 (41%) pts (Figure). Of the other 15 (27%) pts without any documented AF, anticoagulation was withheld in 13 [87%] pts. Following ILR replacement, 33 (80%) of the 41 pts had more AF (n=11 [33%] required an intervention) and 5 additional pts had AF for the first time.

Conclusions

Our data show that after CB PVI, ILRs help guide decisions regarding rhythm management and oral anticoagulation. When the initial ILR was replaced by a second ILR, AF was detected (often for the first time) in some patients; the findings were used to guide clinical decision making in the entire cohort. Thus, at this time, it remains undefined when ECG monitoring of these pts can be stopped because it is no longer clinical meaningful.

Defining the optimal blanking period duration after cryoballoon pulmonary vein isolation in patients with atrial fibrillation who have never been treated with an antiarrhythmic drug

Background

Cryoballoon (CB) pulmonary vein isolation (PVI) is an approved method for ablation in patients with paroxysmal (PAF) or persistent (PeAF) atrial fibrillation (AF). Although the first 90 days post-ablation are considered within the blanking period (BP), the optimal duration of the BP remains undefined.

Purpose

To objectively define the BP duration in pts undergoing CB PVI by evaluating a cohort never treated with an antiarrhythmic drug (AAD).

Methods

We enrolled consecutive pts with either PAF or PeAF who underwent initial CB PVI; all pts had an implantable loop recorder (ILR) for long-term ECG monitoring. No pt received an AAD either before or after ablation. We determined the time to last AF episode within the first 90 days of ablation. We then correlated this to the likelihood a patient had recurrent AF between 91 and 365 days of ablation.

Results

There were 45 pts (67±8 years; 26 [58%] male; 40 [89%] PAF; CHA2DS2-VASc 2.6±1.3). We defined 4 distinct groups post ablation based on whether or not they had AF in the BP: (1) no AF days 0–90 (n=19 [42%]), (2) last AF days 0–30 (n=11 [24%]), (3) last AF days 31–60 (n=3 [7%]), and (4) last AF days 61–90 (n=12 [27%]). After the 90-day BP, 15 (33%) pts had AF recurrence. Pts with no AF and those with AF only within 30 days of ablation had similar long-term outcome; however, recurrent AF more than 32 days after ablation predicted long-term ablation failure (Figure).

Conclusion

The post CB PVI blanking period is just a month. AF recurrences beyond a month in patients not on an AAD are associated with AF recurrence in the majority of pts.

Funding Acknowledgement

Type of funding sources: None. Blanking Group by AF Recurrence

Is the optimal blanking period duration after cryoballoon pulmonary vein isolation impacted by use of antiarrhythmic drugs?

Funding Acknowledgements

Type of funding sources: None.

Background

Cryoballoon pulmonary vein isolation (CB) is an accepted method for ablation in patients with atrial fibrillation (AF). A three-month blanking period (BP) is commonly used in clinical trials and practice. However, when the optimal BP duration differs in patients (pts) on or off an antiarrhythmic drug (AAD) at time of ablation remains undefined.

Objective

To compare the BP duration in pts undergoing CB while either taking or not taking an AAD.

Methods

We enrolled consecutive pts with AF who had CB PVI while on an AAD. All pts had an implantable loop recorder (ILR). We prospectively followed all pts and determined the time to last AF episode during the 90-day post-PVI BP. This was then correlated with likelihood of having an AF recurrence between 3-12 months post-PVI.

Results

The cohort included 164 pts (66 ± 9 years; 97 [60%] male; 90 [55%] PAF; CHA2DS2-VASc 2.7 ± 1.7). Ablation was performed with 92 (56%) pts taking an AAD, which was stopped at a median of 80 [36, 105] days post-PVI. We defined 4 distinct groups: (1) no AF in 90-day BP (n = 75 [46%]); (2) last AF within 30 days of PVI (n = 32 [20%]); (3) last AF within 60 days of PVI (n = 17 [10%]); and (4) last AF within 90 days of PVI (n = 40 [24%]). Following the 90-day BP, 81 (49%) pts had a recurrence of AF. Long-term freedom from recurrent AF was similar in pts who did and did not use an AAD, irrespective of BP duration (Figure).

Conclusion

Our data suggest that the optimal BP duration in AF patients undergoing CB PVI while taking an AAD is 30 days. An AF recurrence after 30 days is associated with a very high likelihood of recurrent AF during longer-term follow-up, irrespective of whether an AAD is being used or not. Abstract Figure.

Defining the blanking period duration after cryoballoon pulmonary vein isolation in patients taking an antiarrhythmic drug

Funding Acknowledgements

Type of funding sources: None.

Background

Cryoballoon pulmonary vein isolation (CB) is an accepted method for ablation in patients with atrial fibrillation (AF). A three-month blanking period (BP) is commonly used in clinical trials and practice. However, the actual BP duration in patients (pts) on an antiarrhythmic drug (AAD) at time of ablation remains undefined.

Objective

To objectively define the BP duration in pts undergoing CB while taking an AAD.

Methods

We enrolled consecutive pts with AF who had CB PVI while on an AAD. All pts had an implantable loop recorder (ILR). We prospectively followed all pts and determined the time to last AF episode during the 90-day post-PVI BP. This was then correlated with likelihood of having an AF recurrence between 3-12 months post-PVI.

Results

The cohort included 92 pts (66 ± 10 years; 62 [67%] male; 33 [36%] PAF; CHA2DS2-VASc 2.6 ± 1.7). AADs used included dofetilide (42), dronedarone (14), amiodarone (25), sotalol and propafenone (3 each), and flecainide (5). The AAD was stopped at a median of 80 [36, 105] days post-PVI.  We defined 4 distinct groups: (1) no AF in 90-day BP (n = 45 [49%]); (2) last AF within 30 days of PVI (n = 17 [18%]); (3) last AF within 60 days of PVI (n = 13 [15%]); and (4) last AF within 90 days of PVI (n = 17 [18%]). Following the 90-day BP, 47 (51%) pts had a recurrence of AF. Once recurrent AF was observed > 30 days post-ablation, patients had high likelihood of having a long term AF recurrence (p = 0.037, Figure).

Conclusion

Our data suggest that the optimal BP duration in AF patients undergoing CB PVI while taking an AAD is 30 days. An AF recurrence after 30 days is associated with a very high likelihood of recurrent AF during longer-term follow-up. Abstract Figure.

P1913Implantable Loop Recorder Detected Pattern of Atrial Fibrillation Recurrence Following Cryoballoon Pulmonary Vein Isolation in Patients with Persistent Atrial Fibrillation

Background

Cryoballoon (CB) pulmonary vein isolation (PVI) is increasingly being used in patients (pts) with persistent atrial fibrillation (AF). However, there are limited data about the pattern of atrial fibrillation (AF) recurrence in these pts.

Objective

To assess, using an implantable loop recorder (ILR), the patterns of AF recurrence following CB PVI in pts with persistent atrial fibrillation.

Methods

We enrolled consecutive pts with persistent AF ablation undergoing their first CB ablation. Other cavotricuspid isthmus ablation when indicated, no other ablation was performed. A Reveal LINQ ILR (Medtronic) was implanted <3 months following ablation; all pts had a minimum of 1-year follow-up. The recurrence of any atrial arrhythmia was determined and adjudicated; 4 distinct AF patterns were characterized (Figure).

Results

We studied 64 pts (66±9 years; 50 [78%] male; CHA2DS2-VASc 2.6±1.9) with persistent AF; 52 (81%) pts were on an antiarrhythmic drug (AAD) peri-ablation. During 803±361 days of follow-up, 33 (52%) pts had their 1st AF recurrence 91–365 days post-ablation and another 17 (27%) pts had their 1st AF recurrence >365 days post-ablation. No AF was seen in 14 (31%) pts. Most pts (33 of 50, 66%) with AF recurrence presented with 1 of 3 distinct patterns of paroxysmal AF (Figure), which ranged from 22 min to 124 hours. In 2/3 of these pts, all AF recurrences lasted <24 hours. Only 17 (34%) pts recurred with persistent AF.

Conclusion

Following single CB PVI, most pts with persistent AF remained free of persistent AF during long-term follow-up. Most pts with recurrent AF have 1 of 3 distinct patterns with episodes commonly last <24 hours. These data suggest that CB PVI ablation may halt AF progression in pts initially presenting with persistent AF.