Clin Res Cardiol (2022). https://doi.org/10.1007/s00392-022-02002-5

Impact of pulmonary vein orifice area on the outcome of cryoballoon-guided pulmonary vein isolation for persistent versus paroxysmal atrial fibrillation
D. Guckel1, K. Isgandarova1, M. El Hamriti1, L. Bergau1, T. Fink1, V. Sciacca1, P. Lucas1, M. Piran2, G. Imnadze1, M. Braun1, M. Khalaph1, G. Nölker3, P. Sommer1, C. Sohns1
1Klinik für Elektrophysiologie/Rhythmologie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen; 2Institut für Molekulare Biophysik, Rardiopharmazie und Nuklearmedizin, Herz- und Diabeteszentrum NRW, Bad Oeynhausen; 3Innere Klinik II / Kardiologie, Christliches Klinikum Unna (CKU), Unna;

Background
Cryoballoon (CB)-guided pulmonary vein isolation (PVI) represents an established treatment for atrial fibrillation (AF). Data on the relationship between individual anatomical characteristics of pulmonary veins (PVs) and the outcome of CB-guided PVI for persistent atrial fibrillation (PERS) compared to paroxysmal atrial fibrillation (PAF) are scarce.

Objectives
The aim of our study was to evaluate the impact of PV cross sectional orifice area (CSOA) from cardiac magnetic resonance imaging (MRI) on the outcome of CB-guided PVI for PERS versus PAF.

Methods
Between 2012 and 2018, a total number of 531 patients undergoing CB-guided PVI with the 2nd generation 28 mm-CB were included (59 ± 21.2 years old, 28% female). 250 patients (47%) (64 ± 10.0 years old, 30% female) suffered from PERS and 281 patients (53%) (51 ± 23.2 years old, 26% female) had PAF. All patients received preprocedural cardiac MRI to assess individual anatomical characteristics of the left atrium and PVs. Follow-up visits were scheduled after 3 and 6 months. For each PV, the CSOA was determined based on the coronal and transversal planes from MRI.

Results
Acute PVI was achieved in all patients (n=531, 100%). AF recurrence occurred in 208 patients (39%). Significantly more PERS patients (n=163, 65%) developed AF recurrence (PRES, n=163; 65% vs. PAF, n=45; 16%; p<0.001*). Normal PV anatomy (2 left- and two right-sided PVs) was found in 216 patients (77%). With regards to the number and distribution of PVs no significant differences were observed between PERS and PAF. Beyond that, no differences were detected with respect to the PV CSOA between patients with PERS versus PAF. PAF patients with AF recurrence presented with significantly larger CSOA of the left sided PVs and the right superior PVs compared to PAF patients without recurrent AF (LSPV: 227.2 ± 96.2 mm2 vs. 218.7 ± 70.3 mm2, p<0.001*; LIPV: 143.4 ± 56.7 mm2 vs. 141.8 ± 52.3 mm2, p<0.001*; RSPV 280.9 ± 80.5 mm2 vs. 264.6 ± 79.1 mm2, p<0.001*). In PERS, we observed no evidence of any association between CSOA and the outcome after CB-guided PVI.

Conclusion
For PAF patients, a significant association between CSOA and the outcome after CB- guided PVI was demonstrated. Thus, pre-procedural LGE-MRI may help to identify PAF patients who benefit most from single shot device guided PVI. In PERS no such relationship could be identified. Due to their progressed state of AF, PERS patients rather seem to profit from individual scar-related ablation strategies than CSOA measurements. Thus, CSOA seems to play a minor role in PERS in contrast to PAF.


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