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Individualized or fixed approach to pulmonary vein isolation utilizing the fourth-generation cryoballoon in patients with paroxysmal atrial fibrillation: the randomized INDI-FREEZE trial
Guidelines/Clinical Documents: Clinical research article from the European Society of Cardiology outlining the INDI-FREEZE trial, a prospective randomized trial aiming at assessing the acute efficacy and clinical outcome of an individualized vs. a fixed ablation protocol using the fourth-generation CB guided by PV potential recordings and CB temperature.
AFib Toolkit: Catheter-based Ablation Procedures: Pulmonary Vein Isolation
Education – Patient/Caregiver: One-page patient education resource explaining Pulmonary Vein Isolation. Includes procedure, post-procedure, procedural risk, and office follow up.
AFib Toolkit: Left Atrial Appendage Closure
Education – Patient/Caregiver: Two-page patient education resources about LAAC. Includes information about the procedure, risk factors, and post-procedure instructions.
AFib Patient Education Toolkit: Blood Clot Prevention, Rate Control, Rhythm Control
Education – Patient/Caregiver: Extensive collection of patient education sheets for 17 different medications used for anticoagulation, rate control, and rhythm control. Each sheet includes how to take the medication, potential interactions, side effects, and warnings.
AFib Toolkit: CHA2DS2-VASc and Your Risk of Stroke
Education – Patient/Caregiver: CHA2DS2-VASc and Your Risk of Stroke
AFib Toolkit: What is Atrial Fibrillation
Education – Patient/Caregiver: Two-page patient education resource explaining AFib, its causes, management and treatment. Includes a description of medications, procedures, and implantable devices, as well ask suggested lifestyle changes.
Once Isolated, Always Isolated? Incidence and Characteristics of Pulmonary Vein Reconduction After Second-Generation Cryoballoon-Based Pulmonary Vein Isolation
Journal Articles: Background—The second-generation cryoballoon delivers effective pulmonary vein isolation (PVI) associated with superior 1-year clinical outcome. However, data on reconduction of previously isolated PV are sparse. Methods and Results—A total of 421 patients underwent second-generation 28-mm cryoballoon-based PVI in 2 centers (St. George’s hospital and Harburg hospital, Hamburg, Germany) between June 2012 and May 2015. Sixty-six of 421 (16%) patients (39/66, 59% women; mean age, 63±10 years, mean left atrium diameter, 45±6 mm) with a history of paroxysmal (40/66, 61%) or persistent atrial fibrillation and atrial tachyarrhythmia recurrences despite previous successful second generation 28-mm cryoballoon-based PVI were included in this analysis. During the index PVI, the standard freeze cycle duration was 240 s. After successful PVI, a bonus freeze cycle of 240 s was applied in the first 15 of 66 (23%) patients, whereas no bonus freeze cycle was applied in the remaining patients. Repeat procedures were performed after a median of 205 (131–357) days following the index ablation. Electric reconduction was assessed for all PVs, and reablation was performed using radiofrequency energy. Persistent electric isolation was noted in 178 of 258 (69%) PVs. In 17 of 66 (26%) patients, all previously targeted PVs remained isolated. A significant difference toward highest reconduction rate for the posteroinferior segment of the right inferior PV was found (P=0.0002). Conclusions—The second-generation cryoballoon ablation is associated with a high rate of persistent PVI. The posteroinferior segment of the right inferior PV showed the highest reconduction rate and seems to be a predilection site for PV reconduction.
Reconduction After Second-Generation Cryoballoon-Based Pulmonary Vein Isolation ― Impact of Different Ablation Strategies
Journal Articles: Background: The second-generation cryoballoon (CB2) has demonstrated high procedural efficacy and convincing clinical success rates for pulmonary vein isolation (PVI). Nevertheless, data on the impact of different ablations protocols on durability are limited. The aim was to comparing the durability of PVI following 3 different ablation strategies in patients with recurrence of atrial fibrillation or atrial tachycardia undergoing repeat procedures. Methods and Results: In 192 patients, a total of 751 PVs were identified. All PVs were successfully isolated during index PVI. Thirty-one out of 192 (16%) patients were treated with a bonus-freeze protocol (group 1), 67/192 (35%) patients with a no bonus freeze protocol (group 2), and 94/192 (49%) patients with a time-to-effect-guided protocol (group 3). Persistent PVI was documented in 419/751 (55.8%) PVs, and in 41/192 (21%) patients, all PVs were persistently isolated. The total rate of PV reconnection was not significantly different between the groups (P=0.134) and the comparison of individual PVs revealed no differences (P-values for RSPV: 0.424, RIPV: 0.541, LSPV: 0.788, LIPV: 0.346, LCPV: 0.865). The procedure times were significantly reduced by omitting the bonus-freeze and applying individualized application times
Three-Year Clinical Outcome After 2nd-Generation Cryoballoon-Based Pulmonary Vein Isolation for the Treatment of Paroxysmal and Persistent Atrial Fibrillation – A 2-Center Experience
Journal Articles: Background: Pulmonary vein isolation (PVI) using the 2nd-generation cryoballoon (CB2) for the treatment of atrial fibrillation (AF) has demonstrated encouraging acute and mid-term results. However, follow-up data on outcomes beyond 1 year are sparse. We investigated the 3-year outcome after PVI using the CB2. Methods and Results: 100 patients with paroxysmal (PAF, 70/100 [70%] patients) or persistent AF (pAF, 30/100 [30%] patients) underwent CB2-based PVI in 2 experienced centers in Germany. Freeze-cycle duration was 240 s. After successful PVI a bonus freeze-cycle of the same duration was applied in the first 71 patients but was omitted in the following 29 patients. Phrenic nerve palsy occurred in 3 patients (3%); 2 patients were lost to follow-up. After a median follow-up of 38 (29–50) months, 59/98 (60.2%) patients remained in stable sinus rhythm (PAF: 48/70 (69%), pAF: 11/28 (39%) P=0.0084). In 32/39 (77%) patients with arrhythmia recurrence, a second ablation procedure using radiofrequency energy was conducted. Persistent PVI was noted in 76/125 (61%) PVs. After a mean of 1.37±0.6 procedures and a median follow-up of 35 (25–39) months, 77/98 (78.6%) patients remained in stable sinus rhythm (PAF: 56/70 (80%), pAF: 20/28 (71%), P=0.0276). Conclusions: CB2-based PVI resulted in a 60.2% single-procedure and a 78.6% multiple-procedure success rate after 3 years. Repeat procedures demonstrated a high rate of durable PVI.
Left Atrial Appendage Isolation in Patients Not Responding to Pulmonary Vein Isolation – Benefit and Risks
Journal Articles: Pulmonary vein isolation (PVI) is an effective strategy for patients with paroxysmal atrial fibrillation (AF).1 However, in patients with persistent AF and long-standing persistent AF, PVI is associated with limited success, with patients not responding to PVI.2 Recently, the BELIEF trial (Effect of Empirical Left Atrial Appendage Isolation on Long-term Procedure Outcome in Patients With Persistent or Longstanding Persistent Atrial Fibrillation Undergoing Catheter Ablation) showed that an electric isolation of the left atrial (LA) appendage (LAA) in addition to PVI could increase clinical success.3 Although potentially effective, this strategy causes electromechanical dissociation of the LAA and was assumed to be associated with increased risk for LAA thrombus and thromboembolism.4 We sought to investigate the incidence of LAA thrombus and thromboembolism and the impact of LAA closure on the prevention of thromboembolic events, in addition to the clinical benefit after left atrial appendage isolation (LAAI).