Department of Cardiology, ZNA Heart Centre, Lindendreef 1, 2020, Antwerp, Belgium.
Heart Rhythm Management Centre, University Hospital Brussels, Brussels, Belgium.
J Interv Card Electrophysiol. 2023 Dec;66(9):2091-2101. doi: 10.1007/s10840-023-01538-4. Epub 2023 Apr 17.
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.
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]).
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).
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.
在房颤（AF）的冷冻球囊消融（CBA）中，15-40%的肺静脉（PV）出现实时 PV 隔离（PVI）缺失，这让人对充分的 PVI 产生了怀疑。本研究旨在确定 CBA 过程中的实时 PVI 是否可预测长期临床结果和 PVI 的耐久性。
803 例 AF 患者（64±10 岁，68%为男性）接受 CBA 治疗。根据无实时 PVI 的 PV 数量，将该队列分为 4 组：无（N=252[31.4%]）、1 个（N=255[31.8%]）、2 个（N=159[19.8%]）和 3-4 个（N=137[17.1%]）。
3 年后，279 例（34.7%）患者出现 AF 复发，其中 188 例再次接受消融治疗。无实时 PVI 的静脉与 AF 复发相关（HR=1.275；95%CI 1.134-1.433；p<0.01），独立于持续性 AF 类型（HR=2.075；95%CI 1.584-2.738；p<0.01）、左心房直径（HR=1.050；95%CI 1.028-1.072；p<0.01）和诊断至消融时间（HR=1.002；95%CI 1.000-1.005；p=0.04）。在所有静脉中，实时 PVI 可实现最高成功率（77.4%），随着无实时 PVI 的静脉数量增加，成功率逐渐降低：1 个静脉为 66.3%，2 个静脉为 58.5%，3-4 个静脉为 48.9%（p<0.001）。在重复消融（N=188）中，分别有 99/430（23.0%）和 83/288（28.8%）个有实时 PVI 和无实时 PVI 的静脉出现再连接（p=0.08）。与无实时 PVI 的右肺下静脉（RIPV）相比，有实时 PVI 的 RIPV 再连接的比例较低：29.7%比 43.7%（p=0.047）。
CBA 过程中实时 PVI 的缺失独立预测 AF 复发，随着无实时 PVI 的静脉数量增加，结果逐渐降低 30%。实时 PVI 对于实现 RIPV 的持久 PVI 尤为重要。
