Regional variations in patient selection and procedural characteristics for cryoballoon ablation of atrial fibrillation

Background

Cryoballoon ablation is a well-established anatomical approach for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Although widely adopted, regional variations in standards of care have not been well characterized.

Purpose

To evaluate regional variations in patient selection and procedural characteristics for PVI with cryoablation in the Cryo Global Registry (NCT02752737).

Methods

Patients with AF were enrolled from May 2016 to October 2021 at 128 sites in 37 countries. Patients were treated with cryoballoon ablation according to local clinical practice. Baseline subject and procedural characteristics were summarized for 8 regions (Central Asia and Russia, East Asia, Europe, Middle East, North America, South Africa, South America, and Southeast Asia). Procedure-related serious adverse events (SAEs) were evaluated in a subset of patients with ≥7 days of follow-up.

Results

A total of 3680 patients undergoing initial PVI for AF were included. Cryoballoon ablation was more commonly performed in patients with paroxysmal vs. persistent AF in all regions, and in males vs. females in all regions except Central Asia and Russia. Mean age ranged from 47±12 in the Middle East to 64±11 in East Asia. Regional variations were observed in the proportion of patients with common AF comorbidities undergoing cryoablation (Table 1). Median procedure time ranged from 61 (49–68) minutes in Central Asia and Russia to 95 (76–120) minutes in Southeast Asia. Median fluoroscopy time was ≤20 minutes in all regions. The use of 3D mapping was relatively uncommon except in North America (63.3%). Large variation was observed in the use of esophageal monitoring, whereas phrenic nerve monitoring was used in ≥97.7% of cases in all regions (Table 2). Same-day discharge was uncommon except in North and South America (37.8% and 26.5% of cases, respectively). Average freeze duration ranged from 153±41 seconds in Southeast Asia to 230±29 seconds in Central Asia and Russia. Mean number of applications per vein ranged from 1.2±0.4 in Central Asia and Russia to 2.1±1.0 in North America. Acute procedural success was ≥94.7% in all geographies and focal radiofrequency touch-up was required in ≤13.0% of cases. In 3126 subjects with ≥7 days of follow-up, 122 procedure-related SAEs were reported in 111 patients (3.6%), and 1 procedure-related death was reported during data collection.

Conclusion(s)

Despite regional variations in patient selection and procedural characteristics, PVI using cryoballoon ablation is performed with high acute success and short procedural times around the world.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic, Inc.

Impact of initial rhythm control with cryoballoon ablation versus drug therapy on atrial fibrillation recurrence and quality of life: results from the Cryo-FIRST study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Medtronic

OnBehalf

The Cryo-FIRST Investigators

Background

Cryoballoon ablation (CBA) as a first-line rhythm control strategy is superior to antiarrhythmic drugs (AADs) for preventing atrial arrhythmia recurrence; however, the impact of first-line CBA specifically on atrial fibrillation (AF) recurrence and quality of life (QoL) has not been well characterized.

Purpose

To compare AF recurrence and QoL following first-line CBA vs. AAD therapy in patients with paroxysmal AF within the CryoFIRST trial (NCT01803438).

Methods

Patients with recurrent symptomatic paroxysmal AF who had not been administered class I or III AAD therapy for >48 hours were enrolled at 18 sites in 9 countries. Patients were randomized (1:1) to CBA or AAD treatment (Class I or III). Subjects were followed by 7-day Holter at 1, 3, 6, 9, and 12 months. Time-to-first AF recurrence outside of a 90-day blanking period was estimated by Kaplan-Meier analysis.  QoL was evaluated using the Atrial Fibrillation Effect on Quality of Life (AFEQT) and 36-Item Short Form Health Survey (SF-36) v2 questionnaires.

Results

Of the 218 randomized subjects, 187 (86%) completed the 12-month follow-up. By intention-to-treat (ITT) analysis, freedom from AF after blanking was achieved in 86.6% in the CBA and 74.5% in the AAD group (p = 0.023).  There was no difference in the time-to-first serious adverse event between groups. In total, 84.3% of patients in the CBA vs. 75.0% of patients in the AAD arm had a clinically important improvement (≥5 points) in the AFEQT summary score.  The adjusted mean difference in the AFEQT summary score at 12 months was 9.9 points higher in the CBA group (95% CI: 5.5-14.2; P < 0.001).  All AFEQT subscale scores were more favorable in the CBA vs. AAD group at 12 months.  There were no significant group differences in any of the SF-36 health domain scores at 12 months in the ITT analysis.  In the per-protocol analysis, clinically important and significant group differences in favor of CBA were observed at 12 months for 3 of 8 SF-36 health domain scores (physical functioning, general health and social functioning).

Conclusion

CBA is superior to AAD for preventing AF recurrence and improving AF-specific QoL in patients with paroxysmal AF. AFEQT Scores at Baseline and 12 MonthsAFEQT Score, Mean ± Standard DeviationCBAAADAdjusted Mean Difference at 12 Months (CBA vs. AAD)p-valueBaseline12 MonthsBaseline12 MonthsDaily Activities65.3 ± 25.887.8 ± 17.161.0 ± 27.976.6 ± 25.48.9 (3.2-14.6)0.002Symptoms59.9 ± 24.888.8 ± 15.658.4 ± 25.280.9 ± 22.27.1 (1.5-12.7)0.014Treatment Concern59.9 ± 23.189.8 ± 14.060.4 ± 24.577.7 ± 22.212.7 (7.9-17.5)<0.001AFEQT, Atrial Fibrillation Effect on Quality of Life questionnaire. CBA, cryoballoon ablation. AAD antiarrhythmic drug.Abstract Figure. Freedom From Atrial Fibrillation

Acute right ventricular failure during aortic root replacement: intraoperative diagnosis and treatment

The scope of this article is to report on a patient who underwent a Bentall procedure for type A aortic dissection. Right ventricular (RV) failure developed immediately after completion of the operation. The etiology was determined by using transit time flow measurement (TTFM), an ultrasound-based technique which demonstrated the absence of blood flow to the right coronary artery. This allowed for early and effective treatment, which was followed by a successful outcome.

The risk of carcinoma in wire localization biopsies for mammographically detected clustered microcalcifications

A total of 183 consecutive patients undergoing biopsies for unilateral microcalcifications concentrated in one or more segments of the breast in the absence of any palpable findings were analyzed to characterize their risk of cancer. Biopsy findings were benign in 86 patients (47%) and malignant in 97 (53%). Of the clinical and mammographic characteristics evaluated, an increasing number of linear microcalcifications, either without a dominant density (p = 0.014) or with a dominant density (p = 0.019) and the presence of heterogeneous microcalcifications (p = 0.055), were associated with a significantly increased risk of malignancy. Conversely a fibronodular parenchymal pattern (p = 0.008) was associated with a significantly decreased risk of malignancy. A high-risk group was identified, 95% (40/42) of whom had malignant biopsy findings, whose mammograms had more than 10 linear microcalcifications not associated with a dominant density (16/17) or at least one linear microcalcification associated with a dominant density (24/25). Conversely a low-risk group for cancer was identified, 88% (28/32) of whom had benign biopsy findings, whose mammograms had exclusively punctate microcalcifications within a fibronodular parenchymal milieu (26/30) or demonstrated some change in the configuration of the microcalcifications on the various mammographic views (10/10). For the remaining 109 patients there was an almost equal division between malignant and benign diagnoses (49% vs 51%).