Abstract
Background
Pulmonary vein isolation (PVI) with 2nd-generation cryoballoon (CB) has been shown to be effective in the treatment of paroxysmal atrial fibrillation (AF). We describe pulmonary vein (PV) reconnection at repeat ablation in patients with AF recurrence after CB PVI and analyze the correlation between the time of AF recurrence and the observed PV reconnection patterns.
Methods
Sixty-six patients undergoing a redo PVI for recurrent AF were enrolled 9.1 ± 2.6 months after the initial CB PVI procedure.
Results
Ninety-two percent had PV reconnections with a mean of 1.97 ± 0.8 reconnected PVs/patient, and 52% of formerly isolated PVs were found reconnected. The highest reconnected rates were observed for left superior PVs (67%). Fifty-three percent of the patients had 2 reconnected PVs, no patient had all PVs reconnected, and 8% were without PV reconnection. There was a significant negative correlation between the time of AF recurrences and the extent of PV reconnections at redo PVI for patients with proven PV reconnection in more than one PV (R = 0.52, p < 0.001), while all patients without PV reconnection had AF recurrences within the first 9 months after PVI.
Conclusions
At redo ablation, most patients with recurrence of AF after CB PVI had PV reconnection(s). Patients with PV reconnection(s) showed a negative correlation between the number of reconnected PVs and the time of AF recurrence with more extensive PV reconnections resulting in earlier PV recurrences after the blanking period. Patients without PV reconnection experienced early AF recurrences, indicating non-PV triggers contributing for paroxysmal AF recurrences in these patients.
Similar content being viewed by others
References
Haissaguerre M, Shah DC, Jais P, Hocini M, Yamane T, Deisenhofer I, et al. Mapping-guided ablation of pulmonary veins to cure atrial fibrillation. Am J Cardiol. 2000;86(9A):9K–19K. https://doi.org/10.1016/s0002-9149(00)01186-3.
Ouyang F, Antz M, Ernst S, Hachiya H, Mavrakis H, Deger FT, et al. Recovered pulmonary vein conduction as a dominant factor for recurrent atrial tachyarrhythmias after complete circular isolation of the pulmonary veins: lessons from double Lasso technique. Circulation. 2005;111(2):127–35. https://doi.org/10.1161/01.CIR.0000151289.73085.36.
Verma A, Kilicaslan F, Pisano E, Marrouche NF, Fanelli R, Brachmann J, et al. Response of atrial fibrillation to pulmonary vein antrum isolation is directly related to resumption and delay of pulmonary vein conduction. Circulation. 2005;112(5):627–35. https://doi.org/10.1161/CIRCULATIONAHA.104.533190.
Callans DJ, Gerstenfeld EP, Dixit S, Zado E, Vanderhoff M, Ren JF, et al. Efficacy of repeat pulmonary vein isolation procedures in patients with recurrent atrial fibrillation. J Cardiovasc Electrophysiol. 2004;15(9):1050–5. https://doi.org/10.1046/j.1540-8167.2004.04052.x.
Spitzer SG, Leitz P, Langbein A, Karolyi L, Scharfe F, Weinmann T, et al. Circumferential pulmonary vein isolation with second-generation multipolar catheter in patients with paroxysmal or persistent atrial fibrillation: procedural and one-year follow-up results. Int J Cardiol. 2017;241:212–7. https://doi.org/10.1016/j.ijcard.2017.04.035.
Knight BP, Novak PG, Sangrigoli R, Champagne J, Dubuc M, Adler SW, et al. Long-term outcomes after ablation for paroxysmal atrial fibrillation using the second-generation cryoballoon: final results from STOP AF post-approval study. JACC Clin Electrophysiol. 2019;5(3):306–14. https://doi.org/10.1016/j.jacep.2018.11.006.
Shah S, Xu W, Adelstein E, Voigt A, Saba S, Jain S. Characterization of pulmonary vein reconnection post Cryoballoon ablation. Indian Pacing Electrophysiol J. 2019;19(4):129–33. https://doi.org/10.1016/j.ipej.2019.02.004.
Aryana A, Singh SM, Mugnai G, de Asmundis C, Kowalski M, Pujara DK, et al. Pulmonary vein reconnection following catheter ablation of atrial fibrillation using the second-generation cryoballoon versus open-irrigated radiofrequency: results of a multicenter analysis. J Interv Card Electrophysiol. 2016;47(3):341–8. https://doi.org/10.1007/s10840-016-0172-z.
Balt JC, Karadavut S, Mulder AA, Luermans JG, Wijffels MC, Boersma LV. Conduction recovery in patients with recurrent atrial fibrillation after pulmonary vein isolation using multi-electrode duty cycled radiofrequency ablation. J Interv Card Electrophysiol. 2013;37(2):197–204. https://doi.org/10.1007/s10840-013-9787-5.
Glowniak A, Tarkowski A, Fic P, Wojewoda K, Wojcik J, Wysokinski A. Second-generation cryoballoon ablation for recurrent atrial fibrillation after an index procedure with radiofrequency versus cryo: different pulmonary vein reconnection patterns but similar long-term outcome-results of a multicenter analysis. J Cardiovasc Electrophysiol. 2019;30(7):1005–12. https://doi.org/10.1111/jce.13938.
Heeger CH, Wissner E, Mathew S, Deiss S, Lemes C, Rillig A, et al. Once isolated, always isolated? Incidence and characteristics of pulmonary vein reconduction after second-generation cryoballoon-based pulmonary vein isolation. Circ Arrhythm Electrophysiol. 2015;8(5):1088–94. https://doi.org/10.1161/CIRCEP.115.003007.
Chun KR, Schmidt B, Metzner A, Tilz R, Zerm T, Koster I, et al. The ‘single big cryoballoon’ technique for acute pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a prospective observational single centre study. Eur Heart J. 2009;30(6):699–709. https://doi.org/10.1093/eurheartj/ehn570.
Westra SW, van Vugt SPG, Sezer S, Evertz R, Hemels ME, Beukema RJ, et al. Second-generation cryoballoon ablation for recurrent atrial fibrillation after an index cryoballoon procedure: a staged strategy with variable balloon size. Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing. 2019;54(1):17–24. https://doi.org/10.1007/s10840-018-0418-z.
Chen S, Schmidt B, Bordignon S, Bologna F, Nagase T, Perrotta L, et al. Practical techniques in cryoballoon ablation: how to isolate inferior pulmonary veins. Arrhythmia Electrophysiol Rev. 2018;7(1):11–7. https://doi.org/10.15420/aer.2018;1;2.
Nery PB, Belliveau D, Nair GM, Bernick J, Redpath CJ, Szczotka A, et al. Relationship between pulmonary vein reconnection and atrial fibrillation recurrence: a systematic review and meta-analysis. JACC Clin Electrophysiol. 2016;2(4):474–83. https://doi.org/10.1016/j.jacep.2016.02.003.
Jiang RH, Jiang CY. Pulmonary vein reconnection in patients with and without atrial fibrillation recurrence after ablation. JACC Clin Electrophysiol. 2016;2(4):484–6. https://doi.org/10.1016/j.jacep.2016.05.004.
Kumagai K, Yasuda T, Tojo H, Noguchi H, Matsumoto N, Nakashima H, et al. Role of rapid focal activation in the maintenance of atrial fibrillation originating from the pulmonary veins. Pacing Clin Electrophysiol. 2000;23(11 Pt 2):1823–7. https://doi.org/10.1111/j.1540-8159.2000.tb07029.x.
Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339(10):659–66. https://doi.org/10.1056/NEJM199809033391003.
Mahida S, Sacher F, Derval N, Berte B, Yamashita S, Hooks D, et al. Science linking pulmonary veins and atrial fibrillation. Arrhythmia Electrophysiol Rev. 2015;4(1):40–3. https://doi.org/10.15420/aer.2015.4.1.40.
Mansour M, Ruskin J, Keane D. Initiation of atrial fibrillation by ectopic beats originating from the ostium of the inferior vena cava. J Cardiovasc Electrophysiol. 2002;13(12):1292–5. https://doi.org/10.1046/j.1540-8167.2002.01292.x.
Lin WS, Tai CT, Hsieh MH, Tsai CF, Lin YK, Tsao HM, et al. Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy. Circulation. 2003;107(25):3176–83. https://doi.org/10.1161/01.CIR.0000074206.52056.2D.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
The study was approved by the ethics committee of University Witten/Herdecke, Germany.
Conflict of interest
The authors declare that they have no conflict of interest.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Wieczorek, M., Sassani, K. & Hoeltgen, R. Is the time of atrial fibrillation recurrence after cryoballoon ablation of paroxysmal atrial fibrillation influenced by the pattern of PV reconnections?. J Interv Card Electrophysiol 60, 321–327 (2021). https://doi.org/10.1007/s10840-020-00804-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10840-020-00804-z