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Second-generation cryoballoon ablation without the use of real-time recordings: A novel strategy based on a temperature-guided approach to ablation

BACKGROUND The achievement of -40°C within the first 60 seconds during cryoenergy applications has proven to independently predict durable pulmonary vein (PV) isolation in the setting of second-generation cryoballoon (CB-A; Medtronic, Minneapolis, MN) ablation. OBJECTIVE We sought to evaluate a strategy based on the attainment of the specific parameter of -40°C within the first 60 seconds during cryoenergy applications in the setting of CB-A ablation without the use of an inner lumen mapping catheter (Achieve, Medtronic) for the visualization of real-time recordings. METHODS A total of 52 patients having undergone CB ablation for paroxysmal atrial fibrillation (AF) between 1 February 2015 and 30 June 2015 who underwent a temperature-guided approach based on achieving -40°C within 60 seconds without real-time recordings (wire group) were compared with a cohort of 52 propensity score-matched patients having undergone CB ablation performed with an inner lumen mapping catheter (Achieve group). All PVs were checked for electrical isolation at the end of the procedure with a circular mapping catheter in the wire group. RESULTS Electrical isolation could be obtained in all patients in the Achieve group and in 99% of PVs in the wire group. Freedom from AF without antiarrhythmic drugs at a mean follow-up of 12.4 ± 3.0 months did not significantly differ between both groups (85% vs 88%, respectively; P = .56). CONCLUSION A temperature-guided approach based on achieving -40°C within 60 seconds is effective in producing PV isolation and affords freedom from AF at 12-month follow-up in 85% of patients affected by paroxysmal AF after a 3-month blanking period.

High recurrence of device-related adverse events following transvenous lead extraction procedure in patients with cardiac resynchronization devices.

Little is known about the clinical outcome and recurring system‐related adverse events (SAE) in cardiac resynchronization therapy (CRT) patients after transvenous lead extraction (TLE).

Efficacy and safety of the second generation cryoballoon ablation for the treatment of paroxysmal atrial fibrillation in patients over 75 years: a comparison with a younger cohort

Aims In this double centre, retrospective study, we aimed to analyse the 1-year efficacy and safety of cryoballoon ablation (CB-A) in patients older than 75 years compared with those younger than 75-years old. Methods and results Fifty-three consecutive patients aged 75 years or older with drug-resistant paroxysmal AF (PAF) who underwent pulmonary vein isolation (PVI) by the means of second generation CB-A, were compared with 106 patients aged <75 years. The mean age in the study group (>75 years) was 78.19 ± 2.7 years and 58.97 ± 8.5 in the control group. At 1-year follow-up the global success rate was 83.6% and did not significantly differ between older (10/53) and younger patients (16/106) (81.1 vs. 84.9%, P = 0.54). Transient phrenic nerve palsy was the most common complication which occurred in eight patients in the younger group and in three in the older group (7.5 vs. 5.7%, respectively, P = 0.66). Conclusions The results of our study showed that CB-A for the treatment of PAF is a feasible and safe procedure in elderly patients, with similar success and complications rates when compared with a younger population.

Role of Electrocardiographic Tpeak-Tend for the Prediction of Ventricular Arrhythmic Events in the Brugada Syndrome

Some previous studies have proposed the electrocardiographic Tpeak-Tend (TpTe) as a possible predictor of ventricular arrhythmic events in patients with Brugada syndrome (BrS). We sought to analyze the association between the parameters of repolarization dispersion (TpTe, TpTe/QT, TpTe dispersion, QTc, and QTd) and ventricular fibrillation/sudden cardiac death in a large cohort of patients with type 1 BrS. A total of 448 consecutive patients with BrS (men 61%, age 45 ± 16 years) with spontaneous (n = 96, 21%) or drug-induced (n = 352, 79%) type 1 electrocardiogram were retrospectively included. At the time of the diagnosis or during a mean follow-up of 93 ± 47 months (median 88 months), 43 patients (9%) documented ventricular arrhythmias. No significant difference was observed in TpTe, TpTe/QT, maximum TpTe, and TpTe dispersion between asymptomatic patients and those with syncope and malignant arrhythmias. TpTe/QT ratio did not also significantly differ between patients with ventricular fibrillation/sudden cardiac death and those asymptomatic ones. In conclusion, TpTe was not significantly prolonged in those patients with type 1 BrS presenting with unexplained syncope or malignant arrhythmic events during follow-up.

Atrial fibrillation ablation with the second generation cryoballoon: Multicenter propensity score matched comparison between freezing strategies

BACKGROUND Second generation cryoballoon (CB-A) ablation is highly effective in achieving pulmonary vein (PV) isolation and freedom from atrial fibrillation (AF). However, the ideal freezing strategy is still under debate. Our objective was to investigate the efficacy and outcome between different freezing strategies used with the CB-A in a multicenter, matched population. METHODS From a total cohort of 1018 patients having undergone CB-A ablation for drug-refractory AF, 673 patients with follow-up ≥6months were included and stratified according to the applied freezing strategy: bonus freeze (BF) versus single freeze (SF). Final population of 256 BF patients was compared with 256 propensity-score matched SF patients. RESULTS BF strategy consisted of 3 different protocols: 3cycles of 180s; 2cycles of 240s; and cycles of 240s followed by 180s in 99/256 (39%); 42/256 (16%); and 115/256 (45%) patients, respectively. SF approach included cycles of 240s in 23/256 (9%), and 180s in 233/256 (91%) patients. Electrical isolation could be achieved in all PVs by both protocols, with shorter procedure and fluoroscopy times in the SF group (mean 106 vs 65min, and 18 vs 14min, respectively, P<0.001). Phrenic nerve palsy persisted after discharge in a total of 11 patients (2.1%): 4 (1.6%) in the BF group vs 7 (2.7%) in the SF group, P=0.5. AF-free survival was similar between the 2 groups during follow-up (mean 18±10months) (log rank, P=0.6). CONCLUSIONS CB-A ablation showed equal efficacy and outcome between SF and BF strategy.

Long-term outcome of pulmonary vein isolation in patients with paroxysmal atrial fibrillation and Brugada syndrome

Aims The therapeutical management of atrial fibrillation (AF) in the setting of Brugada syndrome (BS) might be challenging as many antiarrhythmic drugs (AADs) with sodium channel blocking properties might lead to to the development of ventricular arrhythmias. This study sought to evaluate the clinical outcome in a consecutive series of patients with BS having undergone pulmonary vein (PV) isolation by means of radiofrequency (RF) or cryoballoon (CB) ablation and the efficacy of catheter ablation for preventing inappropriate interventions delivered by implantable cardioverter defibrillators (ICD) on a 3-year follow up. Methods and results Twenty-three consecutive patients with BS (13 males; mean age was 47 ± 18 years) having undergone PV isolation for drug-resistant paroxysmal AF were enrolled. Eleven patients (48%) had an ICD implanted of whom four had inappropriate shocks secondary to rapid AF. Over a mean follow-up period of 35.0 ± 25.4 months (median 36 months) the freedom from AF recurrence after the index PV isolation procedure was 74% without AADs. Patients with inappropriate ICD interventions for AF did not present futher ICD shocks after AF ablation. No major complications occurred. Conclusion Catheter ablation is a valid therapeutic choice for patients with BS and paroxysmal AF considering the high success rates, the limitations of the AADs and the safety of the procedure, and it should be taken into consideration especially in those patients presenting inappropriate ICD shocks due to rapid AF.

Leadless pacing in a young patient with cardioinhibitory vasovagal syncope

Vasovagal syncope is characterized by vasodilatation and/or bradycardia and thereby a fall in arterial BP and global cerebral perfusion in response to a trigger. Although it is a benign condition, patients with frequent and traumatic episodes need treatment in order to improve quality of life. We describe the case of a 17-years-old boy suffering from cardioinhibitory syncope. At the end of a complete negative cardiac and neurological examination, a loop recorder was implanted. During the subsequent follow-up the ILR documented a 9-s pause. To improve the patients compliance, and considering cardioinhibitory syncope as a temporary condition, a leadless pacemaker was eventually implanted.

Single freeze per vein strategy with the second-generation cryoballoon for atrial fibrillation: a propensity score-matched study between 180- and 240-s application time in a large cohort of patients

Aims The single-freeze strategy using the second-generation cryoballoon (CB-A, Arctic Front Advance, Medtronic, Minneapolis, MN, USA) has been reported to be as effective as the recommended double-freeze approach in several single-centre studies. In this retrospective, international, multicentre study, we compare the 3-min single-freeze strategy with the 4-min single-freeze strategy. Methods and results Four hundred and thirty-two patients having undergone pulmonary vein isolation (PVI) by means of CB-A using a single-freeze strategy were considered for this analysis. A cohort of patients who were treated with a 3-min strategy (Group 1) was compared with a propensity score-matched cohort of patients who underwent a 4-min strategy (Group 2). Pulmonary vein isolation was successfully achieved in all the veins using the 28-mm CB-A. The procedural and fluoroscopy times were lower in Group 1 (67.8 ± 17 vs. 73.8 ± 26.3, P < 0.05; 14.9 ± 7.8 vs. 24.2 ± 10.6 min, P < 0.05). The most frequent complication was PNP, with no difference between the two groups (P = 0.67). After a mean follow-up of 13 ± 8 months, taking into consideration a blanking period of 3 months, 85.6% of patients in Group 1 and 87% of patients in Group 2 were free from arrhythmia recurrence at final follow-up (P = 0.67). Conclusion There is no difference in acute success, rate of complications, and freedom from atrial fibrillation recurrences during the follow-up between 3-min and 4-min per vein freeze strategies. The procedural and fluoroscopy times were significantly shorter in 3-min per vein strategy.

Acute and long-term outcomes of simultaneous atrioventricular node ablation and leadless pacemaker implantation

Leadless pacemaker (LDP) allows implantation using a femoral approach. This access could be utilized for conventional atrioventricular nodal ablation (AVNA). It could facilitate unifying the two procedural components. Data regarding its feasibility and long‐term outcomes remain lacking. We aim to evaluate the feasibility and long‐term outcomes of sequential LDP and AVNA.

Impact of an additional right pulmonary vein on second-generation cryoballoon ablation for atrial fibrillation: a propensity matched score study

PurposeCryoballoon (CB) technology in the context of anatomical pulmonary vein (PV) variants might hypothetically hamper successful PV isolation (PVI). Our aim was to assess the impact of a right middle PV (RMPV) in the setting of second-generation cryoballoon (CB advance—CB-A), on procedural parameters and on mid-term follow-up.MethodsConsecutive patients with AF presenting RMPV (RMPV+) at the pre-procedural computed tomography who underwent PVI by CB-A were enrolled. Comparison with propensity score-matched patients without RMPV (RMPV−) was performed. Acute procedural parameters and clinical follow-up were assessed.ResultsA total of 240 patients (80 RMPV+) were included in the analysis. Twelve of 80 (15%) RMPV+ patients underwent a direct cryo-application in this variant and accomplished the isolation without phrenic nerve palsy, whereas in 25 of 80 (31%) RMPV+ patients, the RMPVs were not targeted directly nor indirectly (by co-occlusion during application at a major PV). At a median follow-up of 17.3 [interquartile range 11.3–26.5] months, there was no significant difference in AF-free survival between RMPV+ and RMPV− patients (78.8 vs 78.1%, P = 1.00), and the recurrence of atrial arrhythmias among patients with versus without an intentional or indirect cryo-application to the RMPV was not different (22 vs 20%, P = 1.00).ConclusionsMid-term outcome after CB-A ablation did not differ between RMPV+ and RMPV− patients. Within RMPV+ patients, outcome was similar between those with versus without a cryo-application (either direct or indirect) to the additional vein.