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Radiofrequency catheter ablation for redo procedures after pulmonary vein isolation with the cryoballoon technique

Long-term outcome

Radiofrequenz-Katheterablation bei Rezidiveingriffen nach Pulmonalvenenisolation mittels Kryoballontechnik

Langzeitergebnisse

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Abstract

Background

Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory atrial fibrillation (AF). Cryoablation has been shown to be a safe and effective technique for pulmonary vein (PV) isolation. However, the arrhythmia recurrence rate is high after cryoablation procedures. Radiofrequency catheter ablation has been shown to be an effective strategy for redo procedures in these patients and to provide a favourable outcome during midterm follow-up. The aim of this study was to analyse whether the strategy also provides favourable results during long-term follow-up (5 years).

Methods

In this study 30 patients (paroxysmal AF: 22 patients, persistent AF: 8 patients) underwent a redo procedure after initially successful circumferential PV isolation with the cryoballoon technique (Arctic Front Balloon, Medtronic). The redo ablation procedures were performed using a segmental approach or a circumferential ablation strategy (CARTO; Biosense Webster, Diamond Bar, CA, USA) depending on the intraprocedural findings.

Results

During the repeat procedure, a mean number of 2.9 reconnected PV (SD ± 1.0) were detected. In 20 patients, a segmental approach was sufficient to eliminate the residual PV conduction because only a few PV fibres were recovered (1–3 reconnected PV; group A). In the remaining 10 patients, a circumferential ablation strategy was used because of a complete recovery of the pulmonary vein – left atrial (PV-LA) conduction (group B). All reconnected PV were isolated successfully again. A third or fourth ablation procedure had to be performed in 4 (3 and 1, respectively) patients (13.3%). At 5‑year follow-up, 66.7% of all patients were free from an arrhythmia recurrence (20 out of 30). There were no major complications during long-term follow-up.

Conclusion

In patients with an initial circumferential PV isolation using the cryoballoon technique, a repeat ablation procedure can be safely and effectively performed using radiofrequency catheter ablation providing good long-term follow-up results.

Zusammenfassung

Hintergrund

Die Katheterablation hat sich in den letzten Jahren als Therapieoption bei Patienten mit rezidivierendem, symptomatischem, medikamentös-therapierefraktärem Vorhofflimmern etabliert. Die Kryoablation hat sich hierbei als sicheres und effektives Verfahren zur Pulmonalvenenisolation erwiesen. Dennoch ist die Rezidivrate nach Kryoablation hoch. Die Radiofrequenz-Ablation hat sich als effektive Strategie für Zweiteingriffe bei diesen Patienten bewährt und geht mit günstigen Resultaten im mittelfristigen Verlauf einher. Ziel dieser Studie war es zu analysieren, ob diese Strategie auch positive Ergebnisse im Langzeitverlauf über 5 Jahre zeigt.

Methodik

Insgesamt 30 Patienten (paroxysmales Vorhofflimmern: 22 Patienten, persistierendes Vorhofflimmern: 8 Patienten) mussten sich nach initial erfolgreicher Pulmonalvenenisolation mittels der Kryoballontechnik (Arctic Front; Medtronic) einer Reablation unterziehen. Die Reablation wurde in Abhängigkeit von den intraprozeduralen Befunden entweder als segmental-ostiale oder zirkumferenzielle (Carto; Biosense Websterm, Diamond Bar, CA, USA) Pulmonalvenenreisolation unter Verwendung von gekühlten Radiohochfrequenz-Energieapplikationen durchgeführt.

Ergebnisse

Während des Revisionseingriffs wurde eine Erholung der Pulmonalvenenleitung bei im Mittel 2,9 ± 1,0 Pulmonalvenen dokumentiert. Bei 20 Patienten war eine segmental-ostiale Ablationsstrategie ausreichend, da jeweils nur eine diskrete residuelle Pulmonalvenenleitung bestand (1–3 rekonnektierte PVs; Gruppe A). Bei den übrigen 10 Patienten wurde eine zirkumferenzielle Reablationsstrategie gewählt, da eine komplette Leitungserholung aller 4 Pulmonalvenen vorlag (Gruppe B). Alle Pulmonalvenen mit einem Leitungsrezidiv konnten erfolgreich reisoliert werden. Eine 3. oder 4. Ablationsprozedur wurde bei 4 (3/1) Patienten erforderlich (13,3 %). Während eines Nachbeobachtungszeitraums von 5 Jahren blieben 66,7 % der Patienten ohne Arrhythmierezidiv (20/30). Es traten keine schwerwiegenden Komplikationen im Langzeitverlauf auf.

Schlussfolgerung

Bei Patienten mit Vorhofflimmerrezidiven nach initial erfolgreicher Pulmonalvenenisolation mittels der Kryoballontechnik kann ein Revisionseingriff sicher und effektiv mittels der Radiohochfrequenz-Ablation durchgeführt werden. Hierdurch können gute Langzeitergebnisse erzielt werden.

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Abbreviations

AF:

Atrial fibrillation

CS:

Coronary sinus

ECG:

Electrocardiogram

LA:

Left atrium/left atrial

PV(s):

Pulmonary vein(s)

RF:

Energy applications = radiofrequency energy applications

SD:

Standard deviation

TEE:

Transesophageal echocardiography

3-D TEE reconstruction:

Three-dimensional TEE reconstruction

TIA:

Transient ischemic attacks

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Authors and Affiliations

  1. Department of Cardiology, University of Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany

    Klaus Kettering MD

  2. HPK Heidelberger Praxisklinik für Innere Medizin, Kardiologie und Pneumologie, Heidelberg, Germany

    Felix Gramley MD

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  1. Klaus Kettering MD
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  2. Felix Gramley MD
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Correspondence to Klaus Kettering MD.

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Conflict of interest

K. Kettering and F. Gramley declare that they have no competing interests.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. The study comprised a retrospective analysis of data obtained from clinically indicated routine procedures. There was no funding of the study.

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Both authors have made substantial contributions to the design of the study, to data evaluation and to drafting of the manuscript. They have approved the current version of the manuscript.

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Kettering, K., Gramley, F. Radiofrequency catheter ablation for redo procedures after pulmonary vein isolation with the cryoballoon technique. Herzschr Elektrophys 28, 225–231 (2017). https://doi.org/10.1007/s00399-017-0493-3

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  • DOI: https://doi.org/10.1007/s00399-017-0493-3

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