Cryoballoon ablation for persistent atrial fibrillation - Large single-center experience. Long-term comparison of cryoballoon and radiofrequency ablation of paroxysmal atrial fibrillation: a propensity score matched analysis. Influence of energy source on early atrial fibrillation recurrences: a comparison of cryoballoon vs. radiofrequency current energy ablation with the endpoint of unexcitability in pulmonary vein isolation Electrogram-guided substrate ablation with or without pulmonary vein isolation in patients with persistent atrial fibrillation. Contact-force guided radiofrequency vs. second-generation balloon cryotherapy for pulmonary vein isolation in patients with paroxysmal atrial fibrillation-a prospective evaluation. Circumferential pulmonary vein isolation as index procedure for persistent atrial fibrillation: a comparison between radiofrequency catheter ablation and second-generation cryoballoon ablation. Long-Term Clinical Results of 2 Different Ablation Strategies in Patients With Paroxysmal and Persistent Atrial Fibrillation Circumferential pulmonary vein isolation with the cryoballoon technique results from a prospective 3-center study. Pulmonary venous isolation by antral ablation with a large cryoballoon for treatment of paroxysmal and persistent atrial fibrillation: medium-term outcomes and non-randomised comparison with pulmonary venous isolation by radiofrequency ablation Ganglionated plexus ablation vs linear ablation in patients undergoing pulmonary vein isolation for persistent/long-standing persistent atrial fibrillation: a randomized comparison. Ablation of atrial fibrillation with cryoballoon or duty-cycled radiofrequency pulmonary vein ablation catheter: a randomized controlled study comparing the clinical outcome and safety; the AF-COR study. Outcomes after cryoballoon or radiofrequency ablation for persistent atrial fibrillation: a multicentric propensity-score matched study Differences of two cryoballoon generations: insights from the prospective multicentre, multinational FREEZE Cohort Substudy. Circumferential Pulmonary Vein Ablation With Additional Linear Ablation Results in an Increased Incidence of Left Atrial Flutter Compared With Segmental Pulmonary Vein Isolation as an Initial Approach to Ablation of Paroxysmal Atrial Fibrillation Biatrial linear ablation in sustained nonpermanent AF: Results of the substrate modification with ablation and antiarrhythmic drugs in nonpermanent atrial fibrillation (SMAN-PAF) trial. Incidence and significance of early recurrences associated with different ablation strategies for AF: a STAR-AF substudy. Complex fractionated atrial electrogram or linear ablation in patients with persistent atrial fibrillation--a prospective randomized study. MEDAFI-Trial (Micro-embolization during ablation of atrial fibrillation): comparison of pulmonary vein isolation using cryoballoon technique vs. radiofrequency energy. Surgical vs. transcatheter pulmonary vein isolation as first invasive treatment in patients with atrial fibrillation: a matched group comparison. Substrate and Trigger Ablation for Reduction of Atrial Fibrillation (STAR AF): a randomized, multicentre, international trial† Mesh ablator vs. cryoballoon pulmonary vein ablation of symptomatic paroxysmal atrial fibrillation: results of the MACPAF study. Efficacy of additional ablation of complex fractionated atrial electrograms for catheter ablation of nonparoxysmal atrial fibrillation. Rationale and Design of FIRE AND ICE: A multicenter randomized trial comparing efficacy and safety of pulmonary vein isolation using a cryoballoon versus radiofrequency ablation with 3D-reconstruction.
BACKGROUND Different catheter ablation ( CA ) strategies have been established in the treatment of persistent atrial fibrillation ( persAF ) .  Pulmonary vein isolation ( PVI ) only might be an option for the initial ablation procedure . There is a paucity of outcome data on second-generation cryoballoon ( CBG2 ) PVI in persAF . METHODS Patients with symptomatic drug-refractory persAF who underwent initial CA of AF  were prospect ively enrolled and PVI was performed with CBG2 . The primary composite endpoint was freedom from AF , atrial tachycardia , or related symptoms after a 3-month blanking period . The secondary endpoint referred to periprocedural complications . RESULTS One hundred seventy-three consecutive patients ( 64±10 years , 29 % female ) with symptomatic drug-refractory persAF were identified . Acute PVI was achieved in 100 % of pulmonary veins with the CB technique . The left atrial procedure time was 112±30min . Major complications occurred in 1.7 % ( 3 of 173 patients ) including two phrenic nerve palsies ( 1 % ) , which resolved until discharge , and one pericardial effusion ( 0.6 % ) . Follow-up ≥12 months was completed for 157 of 173 patients ( 91 % ) . Median follow-up was 14 months . At 12 months , the primary composite endpoint was achieved in 129 of 157 patients ( 82 % ) . However , 22 of 129 patients at risk ( 17 % ) were still on antiarrhythmic drugs . A relapse during the blanking period was identified as the only independent predictor for AF recurrence . CONCLUSION PVI using the second-generation cryoballoon is a reasonable treatment option for patients with symptomatic drug-refractory persAF with a favorable rate of freedom from AF and a low complication rate BACKGROUND Although radiofrequency ( RF ) and cryoballoon ( CB ) based technologies for pulmonary vein isolation ( PVI ) have both individually been demonstrated to be effective and safe for the treatment of paroxysmal AF , head-to-head comparisons are lacking . The purpose of this study was to compare the outcome of cryoballoon versus radiofrequency ablation in patients with paroxysmal atrial fibrillation undergoing pulmonary vein isolation . METHODS Out of a prospect i ve registry of 327 patients undergoing PVI , 208 patients ( age 58±11 years , ejection fraction 59±6 % , left atrial size 39±6 mm ) with paroxysmal AF were identified . The presented data set was obtained by 1:1 propensity score matching and contained 142 patients undergoing CB-PVI or RF-PVI in conjunction with a 3D mapping system , respectively . We compared single procedure efficacy of the two methods using a Cox proportional hazards model . RESULTS After a mean follow-up of 28 months and a single procedure , AF recurred in 37 of 71 ( 52 % ) in the CB-PVI group and in 31 of 71 patients ( 44 % ) in the RF-PVI group ( HR [ 95 % CI]=1.19 [ 0.74 , 1.92 ] , p=0.48 ) . Recurrence of AF for PVI using solely the CB was observed in 23 of 51 ( 45 % ) patients and in 23 of 51 ( 45 % ) patients in the corresponding RF-PVI group ( HR [ 95 % CI]=0.93 [ 0.52 , 1.66 ] , p=0.81 ) . Complication rate was not different between the groups . CONCLUSION A propensity score matched comparison between CB-PVI and RF-PVI using a 3D-mapping system for AF ablation showed similar long-term success rates Introduction Comparative data of early recurrence rates of atrial fibrillation ( ERAF )  following second-generation cryoballoon ( CB-G2 ) and radiofrequency current ( RFC ) ablation for pulmonary vein isolation ( PVI ) in paroxysmal AF ( PAF ) are rare . We r and omized PAF patients into either PVI with CB-G2 ( group 1 ) or PVI with a combined RFC-approach applying contact force ( CF ) with the endpoint of unexcitability ( group 2 ) to investigate ERAF . Methods and results In group 1 ( n = 30 ) , CB-G2-PVI was performed . After CF-PVI in group 2 ( n = 30 ) , bipolar pacing on the ablation line and additional ablation until unexcitability was conducted . Follow-up included 48 h of in-hospital monitoring followed by 5-day Holter ECGs 1 , 2 , 3 , 6 , 12 months postablation to evaluate ERAF . Acute PVI was reached in 100 % of group 2 and in 99 % of group 1 . Shorter procedure duration s ( 98.0 ± 21.9 vs. 114.3 ± 18.7 min , P < 0.05 ) but extended fluoroscopy times ( 15.4 ± 3.9 vs. 10.0 ± 4.3 min , P < 0.05 ) were found in the CB-G2 group . Ten non-severe complications occurred ( 6 vs. 4 in group 1 and 2 , P = 0.73 ) . In group 2 , five patients suffered from ERAF vs. seven patients in group 1 ( P = 0.67 ) . The time until the occurrence of ERAF was shorter in group 2 ( 1 day ( q1-q3 : 1 - 4.5 ) ) when compared with group 1 ( 22 ( q1-q3 : 6 - 54 ) days , P = 0.025 ) . Conclusion ERAF rates were equal among groups ; however , they occurred earlier in the initial phase after RFC ablation when compared with CB-G2 . PVI utilizing cryoablation is associated with shorter procedure duration s but extended fluoroscopy time while being similarly secure AIMS Ablation of complex fractionated atrial electrograms ( CFAEs ) is a new approach for the treatment of atrial fibrillation ( AF ) . The purpose of the study was to assess the efficacy of CFAE ablation as a st and -alone strategy in patients with persistent AF and to compare it with a combined approach of CFAE ablation and pulmonary vein isolation ( PVI ) . METHODS AND RESULTS The study included 77 consecutive patients with persistent AF who underwent radiofrequency ( RF ) ablation of CFAE as a sole ablation procedure ( CFAE group , n = 23 patients ) or a combined approach of CFAE ablation and PVI ( CFAE plus PVI group , n = 54 patients ) . Procedures were guided by three-dimensional mapping systems . After the procedure , AF recurrences were evaluated with 7-day Holter recordings at 1 , 3 , and 6 months and every 6 months thereafter . Treatment failure was defined as > or=1 AF episode lasting > 30 s on Holter recordings during follow-up . After a mean follow-up time of 13 + /- 10 months , 2 of 23 patients ( 9 % ) with CFAE ablation and 22 of 54 patients ( 41 % ) with CFAE plus PVI were in sinus rhythm after a single ablation procedure without anti-arrhythmic medication ( P = 0.008 ) . CONCLUSION Ablation of CFAE as a st and -alone ablation strategy seems insufficient for the treatment of patients with persistent AF . Pulmonary vein isolation plus CFAE ablation significantly increases the mid-term success rate AIMS In the setting of paroxysmal atrial fibrillation ( AF ) , there are no available data comparing the mid-term outcome of patients undergoing pulmonary vein isolation ( PVI ) catheter ablation using contact-force (CF)-guided radiofrequency ( RF ) vs. second-generation balloon cryotherapy . METHODS AND RESULTS Prospect i ve single-centre evaluation , carried out from March 2011 to February 2013 , comparing CF radiofrequency ( Thermocool ( ® ) SmartTouch ™ , Biosense Webster , Inc. ) ( CF group ) with cryoballoon ablation ( A rct ic Front Advance ™ 28 mm cryoballoon , Medtronic , Inc. ) ( CB group ) , in regards to procedural safety and efficacy , as well as recurrence at 12 months . Overall , 150 consecutive patients were enrolled ( 75 in each group ) . The characteristics of patients of both the groups were similar ( 61.2 ± 9.9 years , women 25.3 % , mean AF duration 4.1 ± 4.0 years , mean CHA2DS2-VASc score 1.4 ± 1.3 , mean HAS-BLED 1.4 ± 0.6 ) . Duration of the procedure was significantly lower in the CF group ( 110.7 ± 32.5 vs. 134.5 ± 48.3 min , P = 0.001 ) , with a lower duration of fluoroscopy ( 21.5 ± 8.5 vs. 25.3 ± 9.9 min , P = 0.017 ) and X-ray exposure ( 4748 ± 2411 cGy cm² vs. 7734 ± 5361 cGy cm² , P = 0.001 ) . In contrast , no significant difference was found regarding significant procedural complication ( 2.7 vs. 1.3 % in CF and CB groups , respectively ; P = 0.56 ) , and PVI was eventually achieved in all cases . At 12 months , AF recurrence occurred in 11 patients ( 14.7 % ) in the CB group and in 9 patients ( 12.0 % ) in the CF group ( HR = 1.20 95 % CI 0.50 - 2.90 ; log rank P = 0.682 ) . CONCLUSIONS Our preliminary findings suggest that CF-guided radiofrequency and cryotherapy present very similar performances in the setting of paroxysmal AF catheter ablation AIMS To assess the 1 year efficacy of pulmonary vein isolation ( PVI ) as index procedure for persistent atrial fibrillation ( PersAF ) comparing conventional radiofrequency irrigated-tip catheter ablation ( RFCA ) using contact-force technology and ablation using the second-generation cryoballoon ( CB-AdvA ) . METHODS AND RESULTS One hundred consecutive patients ( 74 male , 74 % ; mean age 62.4 ± 9.6 years ) with drug-refractory PersAF undergoing PVI using RFCA and CB-AdvA were enrolled . Follow-up was based on outpatient clinic visits including Holter-electrocardiograms . Recurrence of atrial tachyarrhythmias ( ATas ) was defined as a symptomatic or documented episode > 30 s. Among 100 patients , 50 underwent RFCA whereas 50 CB-AdvA.  Mean procedure and fluoroscopy times were 90.5 ± 41.7 vs. 140.2 ± 46.9 min and 14.5 ± 6.6 vs. 19.8 ± 6.8 min in the CB-Adv and in the RFCA group , respectively ( P < 0.01 ) . At 1 year follow-up , after a 3 months blanking period ( BP ) , freedom from ATas off-drugs after a single procedure was 60 % ( 28/50 patients ) in the CB-Adv and 56 % ( 27/50 patients ) in the RFCA group ( P = 0.71 ) . Multivariate analysis demonstrated that PersAF duration ( P = 0.01 ) and relapses during BP ( P = 0.02 ) were independent predictors of ATa recurrences following the index procedure . CONCLUSION Freedom from ATas following PersAF ablation with RFCA and CB-Adv is comparable at 1 year follow-up after a single procedure . Ablation with the CB-Adv is associated with shorter procedure time and radiation exposure as compared with RFCA . Atrial tachyarrhythmias occurrence during BP and longer time of PersAF seem to be significant predictors of arrhythmia recurrences after the index procedure Background — Data regarding the long-term efficacy of atrial fibrillation ( AF ) ablation are still lacking . Methods and Results —Two hundred four consecutive patients symptomatic for paroxysmal or persistent/permanent AF were r and omly assigned to 2 different ablation schemes : pulmonary vein isolation ( PVI ) and PVI plus left linear lesions ( LL ) . Primary end point was to assess the maintenance of sinus rhythm ( SR ) after procedures 1 and 2 in the absence of antiarrhythmic drugs in a long-term follow-up of at least 3 years . Paroxysmal AF — With a single procedure at 12-month follow-up , 46 % of patients treated with PVI maintained SR , whereas at 3-year follow-up , 29 % were in SR ; using the “ PVI plus LL ” at the 12-month follow-up , 57 % of patients were in SR , whereas at the 3-year follow-up , 53 % remained in SR . After a second procedure , the long-term overall success rate without antiarrhythmic drugs was 62 % with PVI and 85 % with PVI plus LL . Persistent/Permanent AF — With a single procedure at the 12-month follow-up , 27 % of patients treated with PVI were in SR , whereas at the 3-year follow-up , 19 % maintained SR ; using the PVI plus LL with a single procedure at the 12-month follow-up 45 % of patients were in SR , whereas at the 3-year follow-up , 41 % remained in SR . After a second procedure , the long-term overall success rate without antiarrhythmic drugs was 39 % with PVI and 75 % with PVI plus LL . Conclusions —A long-term follow-up of AF ablation shows that short-term results can not be considered permanent because AF recurrences are still present after the first year especially in patients who have had “ PVI ” strategy .  PVI isolation plus LL is superior to the PVI strategy in maintaining SR without antiarrhythmic drugs after procedures 1 and 2 both in paroxysmal and persistent AF OBJECTIVES The purpose of this study was to investigate the efficacy safety of the novel cryoballoon device ( A rct ic Front , Cryocath , Quebec , Canada ) . BACKGROUND Antral pulmonary vein ( PV ) ablation with radiofrequency energy is widely used as a strategy for catheter ablation of paroxysmal atrial fibrillation ( PAF ) . A novel double lumen cryoballoon catheter was design ed for circumferential pulmonary vein isolation ( PVI ) with the cryoablation technique . METHODS We consecutively enrolled 346 patients with symptomatic , drug refractory paroxysmal ( n = 293 ) or persistent ( n = 53 ) atrial fibrillation ( AF ) . In all patients , PVI of all targeted PVs was the therapeutic aim . The primary end points of this nonr and omized study were : 1 ) acute isolation rate of targeted PV ; and 2 ) first electrocardiogram-documented recurrence of AF . The secondary end point was occurrence of PV stenosis or atrio-esophageal fistula . RESULTS The 1,360 of 1,403 PVs ( 97 % ) were targeted with balloons or balloons in combination with the use of Freezor Max ( Cryocath ) . We found that ablation with the cryoballoon result ed in maintenance of sinus rhythm in 74 % of patients with PAF and 42 % of patients with persistent AF . No PV narrowing occurred . The most frequent complication was right phrenic nerve palsy observed during cryoballoon ablation at the right superior PV . CONCLUSIONS Pulmonary vein isolation with a new cryoballoon technique is feasible . Sinus rhythm can be maintained in the majority of patients with PAF by circumferential PVI using a cryoballoon ablation system . Cryoablation was less effective in patients with persistent AF than in patients with PAF Background To prevent  atrial fibrillation ( AF ) recurrence after catheter ablation , pulmonary venous isolation ( PVI ) at an antral level is more effective than segmental ostial ablation . Cryoablation around the pulmonary venous ( PV ) ostia for AF therapy is potentially safer compared to radiofrequency ablation ( RFA ) . The aim of this study was to investigate the efficacy of a strategy using a large cryoablation balloon to perform antral cryoablation with ‘ touch-up ’ ostial cryoablation for PVI in patients with paroxysmal and persistent AF . Methods Paroxysmal and persistent AF patients undergoing their first left atrial ablation were recruited . After cryoballoon therapy , each PV was assessed for isolation and if necessary , treated with focal ostial cryoablation until PVI was achieved . Follow-up with Holter monitoring was performed . Clinical outcomes of the cryoablation protocol were compared , with consecutive patients undergoing PVI by RFA . Results 124 consecutive patients underwent cryoablation . 77 % of paroxysmal and 48 % of persistent AF subjects were free from AF at 12 months after a single procedure . Over the same time period , 53 consecutive paroxysmal AF subjects underwent PVI with RFA and at 12 months , 72 % were free from AF at 12 months ( p = NS ) . There were too few persistent AF subjects ( n=8 ) undergoing solely PVI by RFA as a comparison group . Procedural and fluoroscopic times during cryoablation were significantly shorter than RFA . Conclusions PV isolation can be achieved in less than 2 h by a simple cryoablation protocol with excellent results after a single intervention , particularly for paroxysmal AF BACKGROUND The optimal ablation technique for persistent and long-st and ing persistent atrial fibrillation ( AF ) is unclear . Both linear lesion ( LL ) and ganglionated plexus ( GP ) ablation have been used in addition to pulmonary vein isolation ( PVI ) , but no direct comparison of the 2 methods exists . OBJECTIVE The aim of this study is to assess the comparative safety and efficacy of 2 different ablation strategies-PVI+LL vs PVI+GP ablation -in patients with persistent or long-st and ing persistent AF . METHODS Two hundred sixty-four consecutive patients with persistent/long-st and ing persistent AF were r and omly assigned to 2 different ablation schemes : PVI+LL ( n = 132 ) and PVI+GP ( n = 132 ) ablation . Consistent sinus rhythm ( SR ) off antiarrhythmic drug was assessed after follow-up of at least 3 years with the use of an implanted monitoring device . RESULTS All procedural end points were acutely achieved . At 12 months after a single procedure , 47 % of the patients treated with PVI+LL were in SR compared to 54 % of the patients treated with PVI+GP ( P = .29 ) . At 3 years , 34 % of the patients with PVI+LL and 49 % of the patients with PVI+GP maintained SR ( P = .035 ) . Atrial flutter was more frequent in the PVI+LL group than in PVI+GP group ( 18 % vs 6 % ; P = .002 ) . After a second procedure in 78 patients of the PVI+LL group and 55 patients of the PVI+GP group , the long-term overall success rate was 52 % and 68 % , respectively ( P = .006 ) . CONCLUSIONS PVI+GP ablation confers superior clinical results with less ablation-related left atrial flutter and reduced AF recurrence compared to PVI+LL ablation at 3 years of follow-up AIMS The urge to facilitate the atrial fibrillation ( AF ) ablation procedure has led to the development of new ablation catheters specifically design ed as ' one-shot tools ' for pulmonary vein isolation ( PVI ) . The purpose of this study was to compare the efficacy , safety , and procedure times for two such catheters using different energy sources . METHODS AND RESULTS One hundred and ten patients , referred for ablation of paroxysmal or persistent AF , were r and omized to treatment with either the cryoballoon or the circular multipolar duty-cycled radiofrequency-based pulmonary vein ablation catheter ( PVAC ) .  Complete PVI was achieved in 98 vs. 93 % patients in the cryoballoon and PVAC group , respectively , with complication rates of 8 vs. 2 % ( P = 0.2 ) . Complete freedom from AF , without antiarrhythmic drugs , after one single ablation procedure was seen in 46 % in the cryoballoon vs. 34 % after 12 months ( P = 0.2 ) . Procedure times were comparable , but fluoroscopy time was shorter for the cryoballoon ( 32 ± 16 min ) than for the PVAC procedures ( 47 ± 17 min ) ( P < 0.001 ) . A significant improvement of quality of life ( QoL ) and arrhythmia-related symptoms was seen in both groups after ablation . CONCLUSION Both catheters proved comparably effective and safe in achieving acute PVI , apart from the shorter fluoroscopy times achieved with the cryoballoon . At follow-up , there was no statistically significant difference between the groups regarding freedom from AF and clinical success . The QoL increased to the same levels as for the general Swedish population in both groups Purpose Recent data show no benefit of additional ablation beyond pulmonary vein isolation ( PVI ) in persistent atrial fibrillation ( AF ) . Evidence suggests that radiofrequency energy ( RF ) and cryoballoon ( CRYO ) have comparable efficacy for PVI . We aim ed to assess the outcomes after a single catheter ablation procedure , comparing PVI using CRYO vs. RF ablation for PVI plus additional ablation in a cohort of patients with persistent AF . Methods In this prospect i ve multicenter propensity score-matched comparison , 59 consecutive patients undergoing CRYO ablation of persistent AF were matched to 59 patients treated with RF from November 2010 to June 2012 . Results During a mean follow-up of 15.6 ± 11.5 months , 43.2 % of patients presented atrial arrhythmia relapse after a blanking period of 3 months , which was comparable between the two groups ( 40.7 % in CRYO vs. 45.8 % in RF , Log rank P = 0.14 ; HR = 0.67 , 95 % CI 0.38–1.16 , P = 0.15 ) , despite the fact that 52.5 % of RF patients add additional complex fractionated atrial electrogram ablation , as well as left atrial linear ablation in over two-thirds ( roof line in 67.8 % and mitral isthmus in 32.2 % ) . On multivariate Cox regression , only AF duration in years ( HR = 1.10 , 95 % CI 1.01–1.10 , P = 0.04 ) was a predictor of relapse . Patients undergoing RF ablation presented a numerically , but non-significantly , lower complication rate ( 6.8 vs 10.2 % , P = 0.51 ) . Conclusion In our multicenter experience , freedom from atrial arrhythmias was comparable among matched patients treated with CRYO and RF , despite non-significant trends in favor of RF in terms of complications , at the cost of longer procedure times AIMS Cryoballoon ( CB ) ablation with the second-generation cryoballoon ( CBG2 ) seems to be more effective than its predecessor [ first-generation cryoballoon ( CBG1 ) ] , but phrenic nerve palsies were observed more frequently . The aim of this study was to compare the safety and efficacy of CBG1 and CBG2 in a sub study of the prospect i ve multicentre , multinational FREEZE Cohort Study . METHODS AND RESULTS Periprocedural data were analysed , and a total of 532 patients with paroxysmal atrial fibrillation ( AF ) were examined ( n = 224 for CBG1 and n = 308 for CBG2 ) . Procedure time decreased significantly from 149 to 130 min when comparing CBG1 with CBG2 ( P < 0.0001 ) , and pulmonary vein isolation ( PVI ) was achieved in 97.8 and 97.6 % of PVs with CBG1 and CBG2 ( P = 0.77 ) , respectively . The need for dual-balloon usage within a procedure dropped ( 20.1 vs. 9.0 % , P < 0.001 ) , and the fluoroscopy time was reduced when operating the CBG2 .  Atrial fibrillation recurrence rates until discharge were similar ( 5.0 vs. 5.8 % , P = 0.69 ) . Comparable low rates of major complications were observed with both CBs , and there was a non-significant trend for more phrenic nerve palsies . CONCLUSION Second-generation cryoballoon demonstrated a high rate of acute PVI in a significant faster procedure , which also utilized less radiation exposure and less dual-balloon usage during an average procedure . The safety profile remains favourable with a non-significant trend for more phrenic nerve palsies . If the enhancements lead to a higher clinical benefit has to be determined . The 1-year outcome data from the ongoing FREEZE Cohort Study comparing radiofrequency and CB ablation will shed some light on that issue . CLINICAL TRIALS GOV IDENTIFIER NCT01360008 Background —There has been growing concern that linear ablation is associated with an increased risk of iatrogenic arrhythmias in patients undergoing ablation for atrial fibrillation ( AF ) . Therefore , we compared circumferential pulmonary vein ablation plus left atrial linear ablation ( CPVA+LALA ) with segmental pulmonary vein isolation (PVI)in  patients with paroxysmal AF . Methods and Results —Sixty-six consecutive patients with paroxysmal AF were prospect ively r and omly assigned to receive PVI versus CPVA+LALA ( consisting of encircling lesions around the pulmonary veins ) , a roof line , and a mitral isthmus line with documentation of bidirectional mitral isthmus block . All patients were seen at 1 , 3 , 6 , and every 12 months after ablation , with 14-day continuous ECG monitoring every 6 months . At 16.4±6.3 months after 1 ablation procedure , 19 patients ( 58 % ) remained free of atrial arrhythmias after PVI versus 17 patients ( 51 % ) after CPVA+LALA ( P=0.62 ) . After PVI , 14 patients had recurrent paroxysmal AF , whereas after CPVA+LALA , 8 patients had recurrent AF , 6 had atypical left atrial flutter ( LAFL ) , and 2 had both AF and LAFL ( P=0.32 between PVI versus CPVA+LALA for AF but P=0.002 for LAFL ) . Twenty-eight patients ( 85 % ) remained arrhythmia-free after 1.3±0.5 PVI procedures versus 28 patients ( 85 % ) after 1.4±0.6 CPVA+LALA procedures ( P = NS ) . Fluoroscopy time was longer after CPVA+LALA versus PVI ( 91 versus 73 minutes , P=0.04 ) . Conclusions —As an initial ablation approach in patients with paroxysmal AF  , more LAFL occurred after CPVA+LALA and fluoroscopy times were longer compared with segmental PVI BACKGROUND More advanced atrial fibrillation ( AF ) is associated with lower success rates after pulmonary vein isolation ( PVI ) , and the optimal ablation strategy is uncertain . OBJECTIVES To assess the impact of additional linear ablation ( lines ) compared to PVI alone . METHODS In this multicenter r and omized controlled trial , 122 patients ( mean age 61.9 ± 10.5 years ; left atrial diameter 43 ± 6 mm ) with persistent AF ( PeAF ) or sustained ( > 12 hours ) paroxysmal AF ( SusPAF ) with risk factors for atrial substrate were included and followed up for 12 months . Patients were r and omized to  PVI-only or PVI + lines ( left atrial roof line , mitral isthmus line , and tricuspid isthmus line ) group . Holter monitoring was performed at 3 , 6 , and 12 months and according to symptoms . The primary outcome was atrial tachyarrhythmia recurrence lasting ≥30 seconds . RESULTS Baseline characteristics were comparable between groups ; 61 % had PeAF and 39 % SusPAF . Successful PVI was achieved for 98 % of pulmonary veins , and bidirectional block was obtained in 90 % of lines . The primary end point occurred in 38 % of the PVI + lines group and 32 % of the PVI-only group ( P = .50 ) , which was consistent in both PeAF ( 36 % vs 28 % ; P = .45 ) and SusPAF ( 42 % vs 39 % ; P = .86 ) . Compared with the PVI-only group , the PVI + lines group had higher procedure duration ( 209 ± 52 minutes vs 172 ± 44 minutes ; P < .001 ) , ablation time ( 4352 ± 1084 seconds vs 2503 ± 1061 seconds ; P < .001 ) , and radiation exposure ( Dose-area product 3992 ± 6496 Gy·cm(2 ) vs 2106 ± 1679 Gy·cm(2 ) ; P = .03 ) . Quality of life ( disease-specific Atrial Fibrillation Effect on Quality of Life question naire and mental component scale of the Short Form 36 Health Survey ) improved significantly during the study but did not differ between groups . CONCLUSION Adding lines to wide antral PVI in substrate-based AF requires significantly more ablation , increases procedure duration and radiation dose , but provides no additional clinical benefit BACKGROUND Early recurrences of atrial tachyarrhythmias ( ERAT ) are common after  atrial fibrillation ( AF ) ablation , and predict late recurrences ( LR ) . We sought to determine the impact of different ablation strategies on ERAT and LR . METHODS AND RESULTS The STAR-AF trial r and omized 100 patients with paroxysmal or persistent AF to ablation of complex fractionated electrograms ( CFAE ) alone , pulmonary vein isolation ( PVI ) alone , or combined PVI + CFAE .  Patients were followed for 12 months . ERAT was defined as any recurrence of AF , atrial tachycardia , or flutter ( AT/AFL ) > 30 seconds during the first 3 months of follow-up . LR was defined as any recurrence of AF/AT/AFL > 30 seconds 3 - 12 months post . Forty-nine patients experienced ERAT . The index ablation strategy was the only independent predictor of ERAT on multivariate analysis ( HR 2.24 PVI vs PVI + CFAE ; and HR 2.65 CFAE vs PVI + CFAE ) . Fifty-two patients experienced LR . The presence of ERAT ( HR 3.23 ) , the use of antiarrhythmic drug ( AAD ) in the first 3 months postablation ( HR 2.85 ) , and the index ablation strategy were independently associated with LR ( HR 3.42 PVI vs PVI + CFAE ; HR 4.72 CFAE vs PVI + CFAE ) . Thirty-five of 49 ( 71 % ) patients with ERAT and 17 ( 33 % ) of 51 patients without ERAT had LR ( P < 0.0001 ) . Among patients with ERAT , increased left atrium size ( HR 1.08 ) , the use of AAD in the first 3 months postablation ( HR 2.86 ) and the index ablation strategy were independently associated with LR ( HR 4.77 PVI vs PVI + CFAE ; HR 4.45 CFAE vs PVI + CFAE ) . CONCLUSION ERAT is common following AF ablation and is strongly associated with LR . Although CFAE ablation alone results in higher rates of early and LR , the addition of CFAE to PVI results in increased long-term success without an increase in ERAT BACKGROUND Catheter ablation of complex fractionated atrial electrograms ( CFAE ) for persistent atrial fibrillation ( AF ) is a promising treatment strategy . We tested the hypothesis that CFAE ablation is superior to linear ablation in patients with persistent or long-st and ing persistent AF . METHODS In this study , 116 patients with persistent AF were r and omly assigned to undergo circumferential PVI plus additional lines ( linear ablation group ; 59 patients ) or CFAE ablation plus ostial pulmonary vein isolation ( PVI ) ( spot ablation group ; 57 patients ) . Primary endpoint was freedom from atrial tachyarrhythmia after a single ablation procedure ( clinical and repeat 7-day Holter ) , 12 months after ablation without antiarrhythmic medication . RESULTS The primary endpoint was reached in 22 of 59 ( 37 % ) patients of the linear ablation group and in 22 of 57 ( 39 % ) patients of the spot ablation group ( P = 0.9 ) . Freedom from atrial tachyarrhythmias , including reablations , was achieved in 54 % of patients ( linear ablation group ) versus 56 % of patients ( spot ablation group ; P = 0.8 ) . The incidence of recurrent persistent AF was higher after linear ablation than after spot ablation ( 21/37 vs 11/35 patients ; P = 0.03 ) ; atrial tachycardia ( AT ) was seen more often after spot ablation ( 10/35 vs 4/37 patients ; P = 0.03 ) . CONCLUSION In patients with persistent AF , CFAE ablation plus PVI reaches the same results as circumferential PVI plus lines , in terms of freedom from symptomatic atrial tachyarrhythmias within the first year after a single ablation procedure . Arrhythmia recurrences in patients after spot ablation were caused more often by AT , whereas recurrent persistent AF was more prevalent after the linear ablation approach AIMS Cerebral embolism is a possible serious complication during catheter ablation of atrial fibrillation ( AF ) .  The purpose of this prospect i ve pilot study was to analyse the incidence and possible impact of cryo ablation on cerebral lesions and possible differences to radiofrequency ( RF ) ablation during pulmonary vein isolation ( PVI ) . METHODS AND RESULTS Pulmonary vein isolation was performed in 89 patients , either with the cryoballoon technique ( n = 45 ) or with RF ablation ( n = 44 ) .  Phenprocoumon was stopped 3 days before intervention and replaced by subcutaneous low-molecular-weight heparin . During the catheter procedure , an infusion of unfractionated heparin was maintained to achieve an activated clotting time ( ACT ) of > 300 s. Cerebral magnetic resonance imaging scans were performed 1 day before and after PVI , and at 3-month follow-up . Chronic lesions were observed in 11 patients ( 12.3 % ) before PVI without statistically significant difference between the two groups . None of the patients had neurological symptoms during or following the procedure . Seven patients ( 7.9 % ) developed acute lesions 1 day after PVI , without statistically significant difference between the group treated by cryoenergy ( 8.9 % ) and RF ablation ( 6.8 % ) . Patients with acute lesions were significantly older compared with those without acute cerebral lesions . No additional cerebral lesions during follow-up were observed . CONCLUSION A considerable portion of patients with AF but without any neurological symptoms had chronic cerebral lesions before PVI . Additional acute lesions could be added after the procedure . Both ablation techniques showed additional cerebral acute lesions with no neurological symptoms after PVI AIMS Pulmonary vein isolation ( PVI ) can be considered for treatment of symptomatic atrial fibrillation ( AF ) . Nowadays , in addition to transcatheter ablation , thoracoscopic surgical PVI is available . The aim of this study is to compare clinical outcome of surgical with transcatheter PVI as first invasive treatment strategy of AF . METHODS AND RESULTS From June 2009 to November 2011 , 33 patients underwent minimally invasive surgical PVI , and were matched ( 1:2 fashion ) retrospectively according to age , sex , and AF type , with 66 patients who underwent transcatheter PVI .  Success was defined as freedom from atrial arrhythmias on 24 h Holter monitoring without use of anti-arrhythmic drugs ( AADs ) at 1 year . Mean age was 52 ± 10 years , 82 % were male . Paroxysmal AF was present in 76 patients ( 77 % ) , persistent AF in 23 ( 23 % ) patients . None underwent prior ablations , and failed on 1.2 ± 0.6 AADs . At 12 months , complete freedom from atrial arrhythmias without AADs in the surgical PVI group was 88 % compared with 41 % in the transcatheter PVI group ( P < 0.001 ) . Freedom from atrial arrhythmias with AADs was 91 vs. 62 % , in the surgical vs. transcatheter PVI group , respectively ( P = 0.002 ) . Complications occurred in seven ( 21 % ) surgical PVI patients , and three ( 5 % ) transcatheter PVI patients ( P = 0.015 ) . CONCLUSION In present matched study comparing a surgical with transcatheter PVI treatment strategy in symptomatic AF patients failed on AADs , but without prior ablations , a surgical PVI strategy was more effective to prevent recurrence of atrial arrhythmias , than a transcatheter PVI treatment strategy . However , complications were more frequent with surgical PVI Aims This multicentre , r and omized trial compared three strategies of AF ablation : ablation of complex fractionated electrograms ( CFE ) alone , pulmonary vein isolation ( PVI ) alone , and combined PVI + CFE ablation , using st and ardized automated mapping software . Methods and results Patients with drug-refractory , high-burden paroxysmal ( episodes > 6 h , > 4 in 6 months ) or persistent atrial fibrillation ( AF ) were enrolled at eight centres . Patients ( n = 100 ) were r and omized to one of three arms . For CFE alone ( n = 34 ) , spontaneous/induced AF was mapped using vali date d , automated CFE software and all sites < 120 ms were ablated until AF termination/non-inducibility . For PVI ( n = 32 ) , all four PV antra were isolated and confirmed using a circular catheter . For PVI + CFE ( n = 34 ) , all four PV antra were isolated , followed by AF induction and ablation of all CFE sites until AF termination/non-inducibility . Patients were followed at 3 , 6 , and 12 months with a visit , ECG , 48 h Holter . Atrial fibrillation symptoms were confirmed by loop recording . Repeat procedures were allowed within the first 6 months . The primary endpoint was freedom from AF > 30 s at 1 year . Patients ( age 57 ± 10 years , LA size 42 ± 6 mm ) were 35 % persistent AF . In CFE , ablation terminated AF in 68 % . Only 0.4 PVs per patient were isolated as a result of CFE . In PVI , 94 % had all four PVs successfully isolated . In PVI + CFE , 94 % had all four PVs isolated , 76 % had inducible AF with additional CFE ablation , with 73 % termination of AF . There were significantly more repeat procedures in the CFE arm ( 47 % ) vs. PVI ( 31 % ) or PVI + CFE ( 15 % ) ( P = 0.01 ) . After one procedure , PVI + CFE had a significantly higher freedom from AF ( 74 % ) compared with PVI ( 48 % ) and CFE ( 29 % ) ( P = 0.004 ) . After two procedures , PVI + CFE still had the highest success ( 88 % ) compared with PVI ( 68 % ) and CFE ( 38 % ) ( P = 0.001 ) . Ninety-six percent of these patients were off anti-arrhythmics . Complications were two tamponades , no PV stenosis , and no mortality . Conclusion In high-burden paroxysmal/persistent AF , PVI + CFE has the highest freedom from AF vs. PVI or CFE alone after one or two procedures . Complex fractionated electrogram alone has the lowest one and two procedure success rates with a higher incidence of repeat procedures . Clinical Trials.gov identifier number NCT00367757 AIMS Catheter ablation of the pulmonary veins ( PVs ) is a promising therapeutic approach for symptomatic atrial fibrillation ( AF ) . The prospect i ve r and omized single-centre study ' Mesh Ablator versus Cryoballoon Pulmonary Vein Ablation of Symptomatic Paroxysmal Atrial Fibrillation ' ( MACPAF ; clinical trials.gov NCT01061931 ) compared the efficacy and safety of two balloon-based PV ablation systems . METHODS AND RESULTS Thirty-two patients underwent PV ablation for symptomatic paroxysmal AF using the A rct ic Front ® or the HD Mesh Ablator ® catheter  according to study protocol . The primary endpoint was complete PV isolation ( PVI ) at the end of the ablation procedure , determined by exit block after achieving entrance block . Long-term follow-up data are not included in this publication . Patients ' mean age was 61.7 ± 8.9 years , 43.2 % were female , and median CHA₂DS₂-VASc score was 2.0 . In the intention-to-treat analysis , the rate of the primary endpoint was 56.5 % in patients r and omized to the A rct ic Front ® and 9.5 % in patients r and omized to the HD Mesh Ablator ® catheter ( P = 0.001 ) . In the per- protocol analysis , complete PVI was achieved in 13 ( 76.5 % ) of 17 A rct ic Front ® patients but in none of the 15 HD Mesh Ablator ® patients ( P < 0.0001 ) . There were one major and two minor complications in each study arm but no clinical ly evident stroke . Post-procedural AF recurrence was detected within hospital stay in two ( 11.8 % ) A rct ic Front ® patients and in seven ( 46.7 % ) HD Mesh Ablator ® patients ( P = 0.049 ) . CONCLUSION The MACPAF study revealed a superiority of the A rct ic Front ® catheter concerning complete PVI . Owing to the insufficient efficacy of the HD Mesh Ablator ® catheter , the safety board decided to stop MACPAF prematurely BACKGROUND The efficacy of ablation of complex fractionated atrial electrograms ( CFEs ) in the single ablation procedure for nonparoxysmal atrial fibrillation ( AF ) patients is not well demonstrated . The aim of this study was to compare the ablation strategies of pulmonary vein isolation ( PVI ) plus linear ablation with and without additional ablation ofCFEs in these patients . METHODS Consecutive 60 patients ( 49 + /- 11 years old , 50 male , 10 female ) with nonparoxysmal AF underwent catheter ablation guided by a NavX mapping system .  A stepwise approach included a circumferential PVI and left atrial ( LA ) linear ablation followed by either the additional ablation of continuous CFEs in the LA/coronary sinus ( the first 30 patients ) or not ( the second 30 patients ) , detected by an automatic algorithm . RESULTS There was no difference in the baseline characteristics between the two groups . Complete PVI eliminated some continuous CFEs and altered the distribution of CFEs . Following PVI and linear ablation , the remaining continuous CFEs were identified in 7.9 + /-10 % mapping sites of the LA and CS , and were ablated successfully with a procedural AF termination rate of 53 % . With a follow-up of 19 + /-11 months , a Kaplan-Meier analysis showed that the patients with additional ablation of the CFEs had a higher rate of sinus rhythm maintenance . Multivariate analysis showed the single procedure success could be predicted by the procedural AF termination and the additional ablation of continuous CFEs in the LA/CS . CONCLUSIONS Ablation of continuous CFEs after PVI and LA linear ablation had a better long-term efficacy based on the results of single-ablation procedure BACKGROUND Atrial fibrillation ( AF ) is the most common sustained cardiac arrhythmia imposing substantial morbidity and mortality . Catheter-based pulmonary vein isolation ( PVI ) using radiofrequency current ( RFC ) has become a st and ard treatment for drug-resistant and symptomatic paroxysmal AF ( PAF ) . In recent years , the cryoballoon-based technique is increasingly used as a promising alternative with a short learning curve . METHODS The FIRE AND ICE trial is a prospect i ve , r and omized , controlled , open , blinded outcome assessment , noninferiority trial comparing cryoballoon- , and RFC-based PVI .  Patients with drug-resistant PAF will be r and omized in a 1:1 matrix in multiple European centers . The primary hypothesis is that cryoballoon ablation is not inferior to RFC ablation using 3-dimensional mapping with respect to clinical efficacy . The primary endpoint is defined as the time to first documented clinical failure , including : ( 1 ) recurrence of AF ; ( 2 ) atrial flutter or atrial tachycardia ; ( 3 ) prescription of class I or III antiarrhythmic drugs ; or ( 4 ) re-ablation , whichever comes first , following a blanking period of 3 months after the index ablation procedure . The primary safety endpoint is a composite of death , stroke/transient ischemic attack , cardiac arrhythmias ( apart from AF recurrence ) causally related to the therapeutic intervention , and procedure-related serious adverse events . CONCLUSION The FIRE AND ICE trial compares 2 different technologies to perform catheter ablation of PAF with respect to efficacy and safety . It aims at providing objective data to guide selection and usage of ablation catheters in the treatment of AF
No death or myocardial infa rct ion was reported .
CONCLUSION ' PVI-plus ' involving 2G-CB seems to be safe and effective for treating PerAF
BACKGROUND Growing evidence suggests that second-generation cryoballoon ablation ( 2G-CB ) is effective in patients with persistent atrial fibrillation ( PerAF ) .
The cornerstone of atrial fibrillation ( AF ) ablation is pulmonary vein isolation ( PVI ) .
The purpose of this study was to summarize the available data on the safety and mid-term ( ≥ 12 months ) effectiveness of a ' PVI-only ' strategy vs. a ' PVI-plus ' strategy using 2G-CB in patients with PerAF .