Introduction

The use of single-shot devices for cryoballoon (CB)-guided pulmonary vein isolation (PVI) is widely established in patients with atrial fibrillation (AF). Electrical reconduction of the pulmonary veins is known to be the most common mechanism in terms of arrhythmia recurrence following initial AF ablation. Catheter ablation aiming for reisolation of the pulmonary veins is therefore the standard approach during repeat ablation. 

Aim

This study aimed to access the long-term freedom from arrhythmia recurrence following a simple repeat CBPVI approach in patients with AF recurrence after initial CBPVI.

Methods

The present study screened all patients who underwent CBPVI for symptomatic AF between 2005 and 2012 and included patients who underwent repeat CBPVI due to AF recurrence. Initial CBPVI was performed using the first generation cryoballoon (size: 28mm) according to a standardized institutional protocol. Repeat ablation procedures were conducted using the first- or second-generation CB catheter when there was evidence for PV reconnection. All patients were followed-up (FU) in our outpatient clinic and arrhythmia recurrence was defined as any AF/atrial tachycardia (AT) episode lasting >30s after a blanking period of 3 months. Arrhythmia-free survival was estimated using Kaplan-Meier analysis. Only patients with a FU of ≥9 years after index AF ablation were included in this study.

Results

A total of 107 patients underwent repeat CBPVI for symptomatic AF recurrence after initial CBPVI. 31 patients (29%) were female and mean age was 57±10 years. At initial CBPVI 99 patients (92.5%) presented with paroxysmal AF. Repeat ablation was performed using the first-generation CB in 64 patients (59.8%), while the second-generation CB was used in 43 patients (40.2%). Mean time between first CBPVI and repeat CBPVI was 50.5±4.2 months. After repeat CBPVI, 34 patients (31.8%) experienced arrhythmia recurrence outside of the blanking period. Survival estimation demonstrated an arrhythmia free survival after repeat CBPVI at 12 months of 88.2±3.2% and 55.9±7.3% at 10 years (Figure 1). Procedure related complications occurred in 5 patients (4.7%): one patient with transient phrenic nerve palsy, one patient with pericardial effusion not requiring intervention and three patients with false aneurysm after groin puncture.

Conclusion

CBPVI in patients with AF recurrence after initial CBPVI is safe and effective and leads to comparable long-term results as reported from radiofrequency-guided redo procedures and approaches for substrate modification. A cryoballoon-guided ablation approach can be considered for repeat ablation in selected patients.  

Figure 1 Kaplan-Meier estimation of arrhythmia-free survival after CBPVI for repeat ablation. 

CBPVI = cryoballoon based pulmonary vein isolation