Posterior Wall Isolation Using a Cryoballoon Catheter

Aug 13, 2018
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Authors:
Aryana A, Baker JH, Espinosa Ginic MA, et al.
Citation:
Posterior Wall Isolation Using the Cryoballoon in Conjunction With Pulmonary Vein Isolation Is Superior to Pulmonary Vein Isolation Alone in Patients With Persistent Atrial Fibrillation: A Multicenter Experience. Heart Rhythm 2018;15:1121-1129.
Summary By:
Fred Morady, MD, FACC

Study Questions:

How often can left atrial posterior wall isolation (PWI) be achieved using a cryoballoon catheter, and does this have incremental value in patients with persistent atrial fibrillation (AF) undergoing pulmonary vein isolation (PVI)?

Methods:

In this nonrandomized cohort study, 390 consecutive patients (mean age 67 years) with persistent AF underwent either PVI alone (n = 168) or PVI + PWI (n = 222) using a cryoballoon catheter. Radiofrequency ablation (RFA) was used whenever PVI or PWI was not achieved with the cryoballoon catheter alone. Luminal esophageal temperature was monitored and a cut-off of 15°C was used to terminate applications of cryo-energy. Serial cardiac telemetric monitoring was performed during follow-up.

Results:

PVI and PWI were achieved using only the cryoballoon catheter in 99.7% of PVs and in 67.6% of patients, respectively. In all cases, complete PVI and PWI were achieved using adjunctive RFA. Adverse events were equally infrequent in the two groups. Freedom from atrial tachyarrhythmias at 12 months was significantly higher in the PVI + PWI isolation group than in the PVI group (75% vs. 50%).

Conclusions:

PWI improves clinical efficacy when added to PVI in patients undergoing cryoballoon ablation for persistent AF.

Perspective:

Several surgical and RFA studies have demonstrated the incremental benefit of PWI in patients with persistent AF. This study provides evidence that the same is true with cryo-ablation. However, it is inevitable that esophageal temperature will drop at some point during cryoballoon ablation of the posterior wall, and the temperature cut-off of 15°C used in this study is very aggressive. Because the prevalence of esophageal fistulae is only approximately 0.1%, a sample size of 222 is too small to rule out a possible increase in the risk of this often fatal complication.

Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Esophageal Fistula, Heart Atria, Pulmonary Veins, Secondary Prevention, Tachycardia, Treatment Outcome


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