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The absence of real-time pulmonary vein isolation during cryoballoon ablation is associated with atrial fibrillation recurrence and pulmonary vein reconnection

Insights from the Middelheim-PVI Registry 2

  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Background

Absence of real-time pulmonary vein (PV) isolation (PVI) occurring in 15–40% of PVs during cryoballoon ablation (CBA) of atrial fibrillation (AF) raises doubt about adequate PVI.

Aim of the present study is to determine whether real-time PVI during CBA is predictive of long-term clinical outcome and durability of PVI.

Methods

Eight hundred three AF patients (64 ± 10 years, 68% males) undergoing CBA were studied. The cohort was divided in 4 groups according to the number of PVs without real-time PVI: none (N = 252 [31.4%]), 1 (N = 255 [31.8%]), 2 (N = 159 [19.8%]), and 3–4 (N = 137 [17.1]).

Results

At 3 years, 279 (34.7%) patients had recurrence of AF of which 188 underwent repeat ablation. A vein without real-time PVI was associated with AF recurrence (HR = 1.275; 95% CI 1.134–1.433; p < 0.01), independent of persistent AF type (HR = 2.075; 95% CI 1.584–2.738; p < 0.01), left atrial diameter (HR = 1.050; 95% CI 1.028–1.072; p < 0.01), and diagnosis-to-ablation time (HR = 1.002; 95% CI 1.000–1.005; p = 0.04). Highest success was achieved with present real-time PVI in all veins (77.4%), gradually decreasing per increasing number of absent real-time PVI: 66.3% for 1 vein, 58.5% for 2, and 48.9% for 3–4 veins (p < 0.001). At repeat ablation (N = 188), PV reconnection was seen in 99/430 (23.0%) versus 83/288 (28.8%) veins with and without real-time PVI, respectively (p = 0.08). Right inferior PVs (RIPVs) with real-time PVI were less reconnected than RIPVs without real-time PVI: 29.7% versus 43.7% (p = 0.047).

Conclusion

The absence of real-time PVI during CBA independently predicts AF recurrence with a 30% gradual decrease in outcome per increase in veins without real-time PVI. Real-time PVI is particularly important for the RIPV to achieve durable PVI.

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Data availability

The authors confirm that the data supporting the findings of this study are available within the article. The study data are available from the corresponding author, YDG, upon reasonable request.

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Author information

Author notes

  1. I. Buysschaert and J. P. Abugattas contributed equally to this study.

Authors and Affiliations

  1. Department of Cardiology, ZNA Heart Centre, Lindendreef 1, 2020, Antwerp, Belgium

    Y. De Greef, M. Tijskens, B. Schwagten & M. Wolf

  2. Heart Rhythm Management Centre, University Hospital Brussels, Brussels, Belgium

    Y. De Greef

  3. Cardiology Department, European Interbalkan Medical Center, Thessaloniki, Greece

    D. Sofianos

  4. Department of Cardiology, Heart Centre AZ Sint Jan, Brugge, Belgium

    I. Buysschaert

  5. Department of Cardiology, ULB Erasmus Hospital, Brussels, Belgium

    J. P. Abugattas

Authors
  1. Y. De Greef
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  3. M. Tijskens
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  4. B. Schwagten
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  5. M. Wolf
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Y. De Greef, D. Sofianos, I. Buysschaert, and J.P. Abugattas. The first draft of the manuscript was written by Y. De Greef, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Y. De Greef.

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Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Medical Ethics Committee ZNA, Institutional Review Board-ZNA/OCMW Antwerp, Lindendreef 1, 2020 Antwerp (E.C. Approval N°5570).

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Informed consent was obtained from all individual participants included in the study.

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The authors declare no competing interests.

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De Greef, Y., Sofianos, D., Tijskens, M. et al. The absence of real-time pulmonary vein isolation during cryoballoon ablation is associated with atrial fibrillation recurrence and pulmonary vein reconnection. J Interv Card Electrophysiol 66, 2091–2101 (2023). https://doi.org/10.1007/s10840-023-01538-4

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