Elsevier

Journal of Electrocardiology

Volume 58, January–February 2020, Pages 46-50
Journal of Electrocardiology

Early recurrence of atrial tachyarrhythmia during the 90-day blanking period after cryoballoon ablation in patients with atrial fibrillation: The characteristics and predictive value of early recurrence on long-term outcomes

https://doi.org/10.1016/j.jelectrocard.2019.11.004Get rights and content

Abstract

Objective

To investigate the characteristics of early recurrence (ER) of atrial tachyarrhythmia (ATA) defined as atrial fibrillation (AF), atrial tachycardia (AT), or atrial flutter (AFL) during a 90-day blanking period after pulmonary vein isolation by cryoablation (PVI-C) in patients with symptomatic drug refractory AF. Specifically, to determine if ER of ATA during the blanking period can predict late recurrence (LR) during a 12-month follow-up period.

Method

A total of 51 patients with symptomatic AF (who received PVI-C) were monitored by trans-telephonic wireless electrocardiogram (TWECG) event recording during the landmark 90-day blanking period following an index ablation. Recurrent ATA was defined as any AF, AT, or AFL lasting longer than 30 s (as recorded by 12‑lead ECG, 24-hour Holter monitor, or TWECG). For data analysis, patients were grouped into ER and non-ER cohorts during the 90-day blanking period and then cohorted into LR or non-LR groups during the 12-month follow-up.

Results

During the 90-day blanking period, 23 patients had an ER event of ATA while 28 patients had a non-ER experience. Also, during the 12-month follow-up period, 15 patients had a LR event while 36 patients were free from ATA (and placed in the non-LR cohort). Overall, the average success rate of cryoablation for AF was 70.6% at the 12-month follow-up period. Compared to the non-LR group, patients with LR showed a higher average percentage of diabetes mellitic (33.3% vs. 5.56%; P = 0.008) and had a larger mean left atrium diameter (41.2 ± 4.3 mm vs. 36.5 ± 4.2 mm; P = 0.0006). During evaluation of the 90-day blanking period, the LR group had more frequent attacks of ATA than compared to the non-LR group (27.7% vs. 2.4%; P < 0.001). Only two patients (7.1%) without ER in the blanking period (non-ER cohort) had relapsed into a LR of ATA during the one-year period. After multi-logistic regression analysis, ER could individually predict the risk of LR (RR = 58.8; P = 0.001).

Conclusion

In our study, ER of ATA was a common phenomenon during the 90-day blanking period after PVI-C for AF, and it mostly occurred in the first month following the index ablation across all patients. ER is not equal to the LR of ATA; however, patients with an ER event had a higher risk of a LR during the 12-month follow-up period.

Introduction

Catheter ablation (utilizing a pulmonary vein isolation (PVI) strategy) is an effective management approach for the treatment of patients with symptomatic, anti-arrhythmic drug (AAD) refractory atrial fibrillation (AF) [1]. Additionally, the randomized FIRE AND ICE Trial demonstrated that PVI by cryoablation (PVI-C) is non-inferior to radiofrequency current catheter ablation when treating patients with drug refractory paroxysmal AF (PAF) [2]. According to the expert consensus statement on AF, atrial tachyarrhythmia (ATA) events during the first 90-days after an index ablation should be denoted as a landmark blanking period during which atrial arrhythmias are not counted against longer-term efficacy because the atria are undergoing an extensive physiological healing process [1].

Consequently, recurrence of ATA can be grouped into events occurring within the blanking period (denoted as early recurrence (ER)) and failure events that occur outside of the blanking period during longer-term follow-up (denoted as late recurrence (LR)). Our previous research showed that ER is a widespread phenomenon after radiofrequency catheter ablation in patients with AF and that ER did not predict LR during long-term follow-up [3]. In this current study, we investigated the arrhythmia characters of ER with trans-telephonic wireless electrocardiography (TWECG), 12‑lead ECG, and Holter monitor to determine the relationship between ER and LR following an index PVI-C in patients with AF.

Section snippets

Study population

Consecutive patients with AF (who were received an index PVI-C procedure from August 2015 to July 2016) were evaluated for study enrollment. Inclusion criteria were patients with symptomatic and drug refractory AF (at least one class I or III AAD). Exclusion criteria were based on patient clinical histories, including: 1) patients who had received a previous catheter ablation for atrial arrhythmia; 2) patients with a heart valve disease; and 3) patients who were deemed mentally and/or physical

Baseline characteristic and follow-up

A total of 51 patients (PAF/CAF: 40/11) were enrolled, and all patients finished the 12-month follow-up schedule. In total, 15 patients experienced a LR event resulting in a 70.6% success rate at one- year. For patients with PAF, the one-year success rate was 75.0%, and by comparison, it was 54.5% in patients with persistent AF (PerAF). Of the 51 patients, 23 had an ER event(s) while 28 had no ER event during blanking (Table 1). During follow-up, 15 patients had a LR event(s) while 36 patients

Discussion

Our current study demonstrated that the one-year success rate of PVI-C was 70.6% in a cohort of patients with PAF or PerAF. Furthermore, during the blanking period, the cohort of patients with LR had more frequent attacks of ATA events than compared to the non-LR group (27.7% vs. 2.4%). Patients with LR showed a higher average percentage of diabetes mellitic (33.3% vs. 5.6%) and had a larger mean left atrium diameter (41.2 ± 4.3 mm vs. 36.5 ± 4.2 mm) compared to the non-LR group. Overall, only

Conclusions

In this study, we found that patients with ER were likely to have LR compared to patients that did not have an ER event. The LR rate was 56.5% for patients with ER, but this rate is only 7.1% for patients without an ER event. Furthermore, ER, diabetes, and left atrial diameter were individual predictors of LR. Importantly, ER after PVI-C for AF is still a common phenomenon, and ER often occurs during the first month following an index ablation. Finally, ER does not mean LR, but the patients

Limitation

The small sample size of evaluated patients, the mixed type of AF, and the short-term 24-hour Holter monitoring (non-usage of 7-day Holter) decrease the power of evidence gathered from this data set. Also, all patients in this data set were ablated with the first-generation cryoballoon catheter, and consequently, the general conclusions cannot be fully attributed to the current cryoballoon as an improvement in efficacy is well documented between the two balloon ablation catheters. Further study

Declaration of competing interest

None of the authors have any potential conflicts of interests.

Acknowledgment

We thank Hae Lim for editorial assistance. This research is supported by the Peking Union Medical College Young Fund (ID:2014-XHQN03)

References (9)

There are more references available in the full text version of this article.

Cited by (10)

View all citing articles on Scopus
View full text