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Aims To identify predictors of individual late pulmonary vein (PV) reconnection after second-generation cryoballoon (CB2) ablation. Anatomic indicators of late pulmonary vein reconnection (LPVR) post-CB2 ablation have not yet been studied on an individual PV level, nor weighed against clinical and procedural factors. Methods and results Clinical, procedural, and PV anatomic data from 125 patients with a repeat procedure for arrhythmia recurrence after index CB2 ablation were analyzed. Preprocedural computed tomography (CT) evaluated 486 PVs for measurement of size; shape (ovality index); carina width; and orientation angle in frontal (superior/inferior) and transversal (anterior/posterior) plane (with horizontal line 0° as reference and upper/lower half circle as positive/negative value, respectively). Durable isolation in all PVs was demonstrated in 50/125 (40%) patients. Late reconnection rates at the different PVs were as follows: 16% left superior (LS), 12% left inferior (LI), 17% right superior (RS), and 31% right inferior (RI) PV. Multivariable analysis performed per vein showed following independent determinants predicting LPVR: ovality index [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.07–2.41, P = 0.022] and carina width (OR 0.75, CI 0.59–0.96, P = 0.024) for LSPV; carina width (OR 0.71, CI 0.53–0.95, P = 0.020) for LIPV; frontal angle (OR 0.91, CI 0.87–0.95, P < 0.001) for RIPV; and transversal angle (OR 1.15, CI 1.03–1.31, P = 0.032) for RSPV. Conclusion Cardiac CT-based evaluation of anatomic PV characteristics presented higher predictive value compared to clinical and procedural variables for individual LPVR after CB2 ablation. Pre-procedural identification of unfavourable PV anatomy might be important to tailor the ablation approach.

Background: Clinical management of vaso-vagal syncope (VVS) remains challenging since no therapy has proven to completely prevent VVS recurrence. Objective: The purpose of this study was to analyze the mid-term outcome of cryoballoon (CB) cardioneuroablation achieved by pulmonary vein isolation (PVI) in patients with VVS. Methods: Patients who underwent CB cardioneuroablation in our centers between January 2014 to June 2018 were included. All patients had a history of VVS or pre-syncope despite therapeutic attempts with medical and/or pacing treatments. Patients were excluded in case of structural heart diseases, cerebrovascular diseases or suspected drug-related syncope. Both heart rate (HR) and atrio-ventricular (AV) interval were analyzed on the 12-lead electrocardiogram (ECG) the day before the procedure, the day after, and in the follow-up. Results: In total, 26 patients (76.9% males, 37.5 ± 9.0 years old) were included. All patients underwent a successful procedure with the 28 mm second-generation Arctic Front Advance CB. No major complication occurred. At a mean follow-up of 20.1 ± 11.6 months the freedom from VVS or reflex pre-syncope was 83,7%, with 22 patients free from any clinical recurrence. Basal HR significantly increased the day after the procedure (57.2 bpm vs 78.3 bpm, p

AIM The aim of the study was to investigate the role of anatomical characteristics of the pulmonary veins (PVs) determining cooling kinetics during second-generation cryoballoon ablation (CbA). METHODS AND RESULTS we enrolled all consecutive patients who underwent CbA for symptomatic atrial fibrillation in our center from January 2019 to March 2019. All patients had complete computed tomography scans of the heart before the ablation. Anatomical characteristics were tested for prediction of a nadir temperature (NT) ≤ -48°C. Significant differences were noted among PV max diameter (20.8 ± 2.8 vs 18.5 ± 2.5 mm; P

PURPOSE: High parasympathetic nervous system (PNS) activity is accurately reflected by deceleration capacity (DC) and is involved in atrial fibrillation (AF) recurrence after catheter ablation procedure. When compared with initial catheter ablation procedure, repeated procedures for AF recurrence are followed by a lower success rates, estimated at 50%. Our objective was to evaluate the impact of PNS activity assessed by DC measured before repeated procedure on AF recurrence after repeated procedure. METHODS: Consecutive patients who underwent an initial catheter ablation procedure for pulmonary vein (PV) isolation and a repeated catheter ablation procedure for AF recurrence were selected. Additional 24-h ambulatory electrocardiographic recording between procedures for DC measurement was required for inclusion. A total of 110 patients were included. Seventy-two patients underwent cryoballoon (CB) ablation and 38 patients underwent radiofrequency (RF) ablation as initial procedure, while all patients underwentRF ablation as repeated procedure. RESULTS: DC was higher in cases with right-sided PV reconnection (p = 0.04, OR = 1.38, 95% CI = 1.08-1.78). In patients with CB ablation as initial procedure, DC was higher in patients with PV reconnection (p = 0.03, OR = 1.29, 95% CI = 1.11-1.70), and the number of reconnected PVs was higher in patients with DC ≥ 7.0 ms (median DC value used for dichotomization, p = 0.02, OR = 2.19, 95% CI = 1.10-4.37). In multivariate Cox regression, DC predicted AF recurrence after repeated ablation (p = 0.004, HR = 1.68, 95% CI = 1.35-1.82). In multivariate binary regression, DC predicted persistent AF type recurrence after repeated ablation (p = 0.01, OR = 1.50, 95% CI = 1.10-2.02). CONCLUSIONS: DC is a novel predictor of AF recurrence and AF recurrence type after repeated catheter ablation procedure. DC may reflect the need of more intensive treatment strategies in patients with high PNS activity.

PURPOSE: Currently, information on the mid-term outcome of cryoballoon ablation (CB-A) for drug-resistant atrial fibrillation in patients with reduced left ventricular systolic function is limited. METHODS: Thirty-eight consecutive patients with paroxysmal or persistent atrial fibrillation (84.2% male), with median left ventricular ejection fraction of 37.3% were included in our study. All patients underwent the procedure with the 28-mm cryoballoon advance. RESULTS: There were no mayor complications related to the CB-A procedure. Median follow-up was 26.5 ± 13.7 months. The freedom from atrial fibrillation after a blanking period of 3 months was 42.9% in our cohort of patients. During the follow-up period, 13 patients underwent at least a new electrophysiological procedure. After a single procedure, the univariate predictors of clinical recurrence after the blanking period were age and persistent atrial fibrillation. CONCLUSION: Second-generation CB-A of atrial fibrillation seems feasible and safe in patients with heart failure with reduced ejection fraction and heart failure with mid-range ejection fraction, in terms of complications rate and number of applications per vein. All pulmonary veins could be isolated with the 28-mm cryoballoon advance only.

INTRODUCTION The right inferior pulmonary vein (RIPV) accounts as the most frequently reconnected vein after pulmonary vein isolation using second-generation cryoballoon ablation (CB-A). Our objective was to assess anatomic predictors of late RIPV reconnection based on preprocedural computed tomography scan. METHODS Patients with a repeat procedure for atrial tachyarrhythmia recurrence after index CB-A procedure were included. A total of 129 RIPVs were evaluated for ostial diameters, ostial area, and branching pattern. Interior angle between RIPV and horizontal line in the frontal/transversal plane was used to measure the RIPV orientation: RIPV frontal/transversal angle, respectively. In addition, interior angle between RIPV and the line perpendicular on the septal intersection line at the level of the fossa ovalis, estimated as trans-septal (TS) puncture site, was measured in the frontal/transversal view: RIPV-TS frontal/transversal angle, respectively. RESULTS Late vein reconnection was present in 36/129 RIPVs (28%). Warmer balloon nadir temperature (P = .01), more inferior (P

PURPOSE: The purpose of this study was to analyze the efficacy and complication rates of a one-stage left unilateral thoracoscopic hybrid procedure in a series of patients with persistent and long-standing persistent atrial fibrillation (AF) in a 2-year follow-up. METHODS: Fifty-one consecutive patients (34 males, 65.7 ± 8 years) having undergone hybrid isolation of pulmonary veins (PVs) and posterior wall of left atrium (LA) by means of left unilateral hybrid thoracoscopic ablation for symptomatic persistent (n = 22, 43%) and long-standing persistent atrial fibrillation (AF) (n = 29, 57%) were analyzed. RESULTS: At a mean follow-up of 24.9 ± 11.8 months (median 24), the success rate without antiarrhythmic therapy was achieved in 68.6% of patients. Procedure-related major complications were observed in 2 patients (4%) including diaphragmatic perforation and late pericardial tamponade requiring mini left-sided thoracotomy and pericardial drainage, respectively. The success rate did not significantly differ between persistent and long-standing persistent AF (respectively, 68.2 and 69%; P = 0.89). Patients with AF relapse during the blanking period were 3.8 times more likely to have AF recurrence after 3 months from the ablation procedure. CONCLUSION: The hybrid one-stage left unilateral thoracoscopic procedure exhibits encouraging results in the setting of both persistent and long-standing persistent AF after a 2-year follow-up, at a low rate of adverse events.

Background Abnormal delayed electrograms (EGMs) from the anterior wall of the right ventricular outflow tract (RVOT) epicardium have become the ablation target in Brugada syndrome (BrS). Objective The aim of this study was to analyze the safety, feasibility, and efficacy of a novel hybrid thoracoscopic approach to perform epicardial RVOT radiofrequency ablation in BrS. Methods Thirty-six patients with BrS (26 men (72.2%); mean age 36.6±15.8 years; range 3–63 years) who underwent hybrid thoracoscopic epicardial ablation of RVOT from January 2016 to April 2018 were included in this study. Two expert electrophysiologists analyzed the EGMs during ajmaline challenge and guided the surgeon to perform ablation. Ajmaline challenge was repeated after 1 month to assess the absence of the BrS electrocardiographic pattern. Patients were followed by remote monitoring and outpatient visits every 6 months. Results The elimination of all abnormal EGMs was achieved in 94.4% of patients. After a mean follow-up of 16 ± 8 months (range 6–30 months), freedom from ventricular arrhythmias was obtained in 7 (77.8%) patients in secondary prevention 9/36 (25%) and in 24 (100%) patients in primary prevention 24/36 (75%). Major complications were observed in 1 patient (2.8%), who experienced late cardiac tamponade. Conclusion Hybrid thoracoscopic epicardial RVOT ablation in BrS is a safe and feasible approach, allowing direct visualization of ablation during radiofrequency delivery. Because of ventricular arrhythmia recurrences, implantable cardioverter-defibrillator implantation is still mandatory in patients treated in secondary prevention and with high risk.

Aims The main cause of atrial fibrillation recurrence after catheter ablation is pulmonary vein reconnection. The purpose of this retrospective study was to analyse the electophysiological findings in patients undergoing repeat procedures after an index cryoballoon ablation (CB-A) and presenting with permanency of pulmonary vein isolation (PVI) in all veins. In addition, we sought to compare the latter with a similar group of patients with reconnected veins at the redo procedure. Methods A total of 132 patients (81 men, 60.7 ± 12.4 years) who underwent CB-A for paroxysmal atrial fibrillation (PAF) were enrolled. Indication for the redo procedure was symptomatic PAF in 83 (63%), persistent atrial fibrillation (PerAF) in 32 (24%) or persistent regular atrial tachycardia (RAT) in 17 (13%) patients. Results Seventy-five (57%) patients presented a pulmonary vein reconnection (pulmonary vein group) during the redo procedure, whereas 57 (43%) had no pulmonary vein reconnection (non-pulmonary vein group). The non-pulmonary vein group exhibited significantly more non-pulmonary vein foci and atrial flutters than the pulmonary vein group after induction protocol (51 vs. 24%, P = 0.002 and 67 vs. 36%, P = 0.003, respectively). Twenty-two (29.3%) patients of the pulmonary vein group and 20 (35%) patients of the non-pulmonary vein group had atrial fibrillation/RAT recurrence after a mean follow-up of 12.5 ± 8 months. The survival analysis demonstrated no statistical significance in recurrence between both groups (log rank P = 0.358). Conclusion Atrial fibrillation/RAT recurrence in patients after CB-A with durable PVI is significantly associated with non-pulmonary vein foci and atrial flutters. No statistically different success rate regarding atrial fibrillation/RAT freedom was detected between the pulmonary vein and non-pulmonary vein groups after redoing RF-CA.

BACKGROUND: The impact of pulmonary vein isolation (PVI) performed with cryoballoon (CB) on the intrinsic cardiac autonomic nervous system (ICANS) remains unclear. OBJECTIVE: The purpose of this study was to evaluate the predictors and the clinical meaning of cardiac neuromodulation achieved by CB-ablation as assessed by sinus heart rate (HR) response after the procedure. METHODS: Patients who underwent CB-ablation for drug-resistant atrial fibrillation (AF) from January 2014 to October 2018 were included. Twelve‑leads rest ECG was taken both before and after the procedure. After discharge, patients were scheduled for follow-up visits at 1, 3, 6, and 12 months and 24 h Holter recordings were obtained at each follow-up visit. All documented AF episodes of >30 s were considered as recurrence. RESULTS: Four-hundred seventy-two patients (62.3% male, age 56.7 ± 13.6 years, 97.2% paroxysmal AF) were included. Mean HR before the procedure was 60.17 ± 10.4 bpm, while the morning after the procedure mean HR was 75.48 ± 12.0 bpm. Age at enrollment (R = -0.26; p < 0.001), baseline HR before the CB-A (R = -0.32; p < 0.001), nadir temperature in each right pulmonary vein (R = -0.11, p = 0.022; R = -0.16; p = 0.001) were significantly associated with the ∆HR. At 2-year follow-up, freedom from recurrences was 83.1% for the patients with HR increase ≥15 bpm after CB-A and 66.3% in patients with HR increase ˂15 bpm (p = 0.021). CONCLUSION: Sinus HR increase is a frequent phenomenon after CB-A, that can be predicted by both clinical and procedural factors and that correlates with better outcome after cryo-PVI.

Brugada syndrome (BrS) diagnosis requires the presence of a typical type 1 ECG pattern. Owing to the spontaneous ECG variability, the real BrS prevalence in the general population remains unclear. The aim of the present study was to evaluate the prevalence of positive ajmaline challenge for BrS in a cohort of consecutive patients who underwent electrophysiological evaluation for different clinical reasons. All consecutive patients from 2008 to 2019 who underwent ajmaline testing were prospectively included. A total of 2,456 patients underwent ajmaline testing, 742 (30.2%) in the context of familial screening for BrS. In non-familial screening group (1,714) ajmaline testing resulted positive in 186 (10.9%). Indications for ajmaline testing were: suspicious BrS ECG in 23 cases (12.4%), palpitations in 27 (14.5%), syncope in 71 (38.2%), presyncope in 7 (3.8%), family history of sudden cardiac death in 18 (9.7%), documented ventricular arrhythmias in 12 (6.5%), unexplained cardiac arrest in 4 (2.2%), atrial fibrillation in 16 (8.5%), brady-arrhythmias in 1 (0.5%), and cerebrovascular accidents in 7 (3.7%). Compared with the overall population, ajmaline testing positive patients were younger (42.8 ± 15.5 vs 48.9 ± 20.4; p

Introduction The purpose of this study was to analyze and compare the electrophysiological findings in redo radiofrequency (RF)-ablation of AF in a series of patients with durable PV isolation (PVI) and with PV reconnection after index procedure with the second-generation cryoballon (CB). Methods and results A total of 132 patients (81 males, 60.7 ± 12.4 years) who underwent CB-A for paroxysmal AF (PAF) were enrolled. Indication for the redo procedure was symptomatic (PAF) in 83 (63%) and persistent AF (PeAF) or persistent regular atrial tachycardia (RAT) in 49 (37%). Seventy-five (57%) patients presented a PV reconnection (PV group), whereas 57 (43%) no PV reconnection (non-PV group). The non-PV group exhibited significantly more atrial flutters and non-PV foci than the PV group after induction protocol (67% vs. 36%, p = 0.003 and 51% vs. 24% p = 0.002, respectively) (Table 1). Twenty-two (29.3%) patients of the PV group and 20 (35%) patients of the non-PV group had AF/RAT recurrence after a mean follow-up of 12.5 ± 8 months. The survival analysis demonstrated no statistical significance in recurrence between the two groups (log rank p = 0.358). In the cox regression analysis only the AF/RAT recurrence in the blanking period could predict independently an AF/RAT relapse. Conclusions AF/RAT recurrence in patients after CB-A with durable PVI is significantly associated to atrial flutters and non-PV foci. No statistically different success rate regarding AF/RAT freedom was detected between PV and non-PV Group after redo RF-CA. Table 1. Electrophysiological findings PV Groupn = 75 non-PV Groupn = 57 p-value PV trigger (n of patients) 75(100) 0(0)

AIM The aim of this study is to assess specific per-vein procedural predictors of pulmonary vein (PV) late reconnection in cryoballoon ablation (CbA) METHODS AND RESULTS: We enrolled 148 consecutive patients undergoing a redo procedure after a previous index CbA in our center. A reconnection in at least one PV was found in 80 patients (54.1%) and the most frequently reconnected PV was the right inferior pulmonary vein (RIPV). Overall, pulmonary vein reconnection (PVr) was associated with longer time to -40°C (Tt-40°C) (54.4 ± 21.7 vs 67.6 ± 27.6 seconds; P

Owing to a type error during final correction and proof data submission to the journal, there were mistakes introduced into the legends of Fig. 3 and Fig. 4 as well as into the Y-axis title of the plot of Fig. 4.

PURPOSE: There is still sparse information regarding phrenic nerve palsy (PNP) during the cryoablation of both right-sided pulmonary vein (PV) and its anatomical predictors. METHODS: Consecutive patients who had undergone pulmonary vein isolation (PVI) using CB-A and suffered PNP during both right-sided PVs were retrospectively included in our study. Two other groups were then selected among patients who experienced PNP during RIPV application only (group 2) and RSPV application only (group 3). RESULTS: The incidence of PNI during both right-sided PVs cryoapplications was 2.1%, (32 of 1542 patients). There were no significant clinical differences between the 3 groups. Time from basal temperature to -40 °C significantly differed among the groups for both RIPV (p = 0.0026) and RSPV applications (p = 0.0382). Patients with PNP occurring during RSPV applications had significantly larger RSPV cross-sectional area compared to patients without PNP (p = 0.0116), while in patients with PNP during RIPV application, the angle of RIPV ostium on the transverse plane was significantly smaller compared to patients without PNP (p = 0.0035). The carina width was significantly smaller in patients with PNP occurring during both right-sided PVs cryoapplications compared to patients in which PNP occurred only during one right-sided PV application (p

Background A left common pulmonary vein (LCPV) accounts as the most frequent pulmonary vein (PV) variation. Our aim was to compare the performance of radiofrequency (RF) versus second-generation cryoballoon (CB-A) ablation in patients with atrial fibrillation (AF) and LCPVs. Methods In a total cohort of 716 patients undergoing PV isolation with preprocedural CT-scanning, LCPV+ patients were selected with measurement of PV ostial area and trunk distance. All LCPV+ patients were matched between RF and CB-A group in a 1:1 ratio based on propensity scores, and compared for outcome. Results Left common pulmonary veins were found in 31% (88/283) RF versus 34% (146/433) CB-A patients, respectively, (P = .44). In the matched population of 83 LCPV+ patients in each group, electrical isolation could be achieved in all left-sided PVs. No significant difference was noted for the rate of AF/left atrial tachyarrhythmia (LAT) recurrence between RF and CB-A group (30% vs 28%, P = .86), with similar AF/LAT-free survival (log rank, P = .71). There were 48 patients with AF/LAT recurrence (29%) during the follow-up. Recurrence rate between paroxysmal versus persistent AF was 27/120 (22.5%) versus 21/46 (46%), P = .004. Cox proportional regression analysis withheld LA volume and persistent AF as independent variables to predict AF/LAT recurrence. No increased hazard for AF/LAT recurrence was observed for patients with a long (>15 mm) vs short (5-15 mm) LCPV trunk (OR 1.14, 95% CI 0.6-2.2, P = .7). Conclusions In our study, equal efficacy and outcome was noted in LCPV+ patients between RF and CB-A technology.

AIMS: The purpose of this study was to systematically quantify the level of acute parasympathetic denervation in a stepwise fashion by means of extracardiac vagal stimulation (ECVS) by positioning a quadripolar catheter in the internal jugular vein, in a cohort of patients undergoing second-generation cryoballoon ablation for paroxysmal atrial fibrillation. METHODS: Fifty patients with symptomatic paroxysmal atrial fibrillation, having undergone extracardiac vagal stimulation before and after ablation by means of second-generation cryoballoon second-generation cryoballoon ablation, were included. RESULTS: The extracardiac vagal stimulation performed preablation provoked cardioinhibitory responses in all patients with mean pause duration of 10130.6 ± 3280.0 ms. At the end of the procedure, the VRs were significantly diminished with mean pause of 1687.5 ms ± 2183.7 ms (P = 0.00 compared with the pause before the procedure). CONCLUSION: The ECVS proved to be a reproducible, feasible and reliable method to quantify the degree of parasympathetic denervation during CB-A. In all patients, significant cardiac parasympathetic denervation could be observed at the end of the procedure. Responses to ECVS were more specific to quantify the vagal denervation than the increase in the heart rate. However larger studies are needed to confirm this observation.

BACKGROUND: The creation of a posterior box isolation of the left atrium (LAPWI) in addition to pulmonary vein isolation (PVI) with the second-generation cryoballoon (CB-A) seems to offer promising clinical outcome in patients affected by persistent atrial fibrillation (PersAF). AIM: This work aims to study the clinical outcome of an ablation strategy based on the creation of a LAPWI during repeat procedures for recurrent AF after an index CB-A procedure for PersAF. METHODS AND RESULTS: A total of 33 patients having undergone a repeat procedure consisting in redo PVI plus LAPWI for recurrent PersAF with the CB-A after an index PVI ablation were retrospective included in our study. Electrical reconnection could be documented in 18 veins (13%). The LAPW was successfully isolated solely by CB-A ablation in 30 out of 33 (91%) patients; in the remaining 3 patients, isolation of the LAPW was completed by focal tip-irrigated RF ablation. The mean number of CB-A applications required for the superior portion of theLAPW and the inferior portion of the LAPW creation were 5.4 ± 0.9 and 4 ± 0.6, respectively. After a mean follow-up of 11.8 ± 3 months, 28 patients (85%) did not experience recurrence of any atrial arrhythmias during follow-up, without the need of further ablation or class I or III AADs. CONCLUSION: Left posterior wall isolation with the CB-A is feasible and safe during repeat ablation procedures for recurrent PersAF. In our study, the 12-month freedom from any arrhythmia was 85% following this ablation strategy.

PURPOSE: The purpose of this study was to clarify the behavior of the luminal esophageal temperature (LET) in a cohort of patients undergoing second-generation cryoballoon (CB-A) for pulmonary vein isolation (PVI) and additional left atrium posterior wall (LAPW) ablation by means of CB-A. METHODS: Thirty patients with symptomatic persistent AF (PersAF), having undergone PVI + LAPW cryoballoon ablation with LET monitoring. RESULTS: Interruption of the application due to a LET below 15 °C occurred in 5 patients (16.6%), 2 at the LIPV and 3 in the LAPW. The 5 patients underwent gastroscopy the day after ablation. In all individuals, esophageal thermal lesion (ETL) was absent. CONCLUSION: The evaluation of LET might be an additional tool in helping to prevent damage to the esophagus during the LAPW ablation with the CB-A by stopping the freeze application when temperature reaches values of

PURPOSE: The purpose of the present study was to assess the long-term success rate of a single 3-min freeze per vein ablation strategy in the setting of pulmonary vein isolation (PVI) by means of second-generation cryoballoon (CB-A; Arctic Front Advance, Medtronic, Minneapolis, MN, USA) in a large cohort of patients. METHODS: Three hundred and one patients with drug resistant atrial fibrillation (AF) having undergone PVI by means of CB-A using a single 3-min freeze per vein ablation strategy were included in the analysis. RESULTS: Paroxysmal AF (PAF) was documented in 70.8% of the patients, while 29.2% presented with persistent AF (PersAF). The mean number of CB applications was 1.09 ± 0.3 in the left superior pulmonary vein (LSPV), 1.04 ± 0.2 in the left inferior pulmonary vein (LIPV), 1.12 ± 0.3 in the right superior pulmonary vein (RSPV), and 1.12 ± 0.3 in the right inferior pulmonary vein (RIPV). All PVs were successfully isolated with a 28-mm CB-A only. After a mean follow-up of 38.1 ± 7.5 months, 207 (68.8%) patients were free of atrial tachyarrhythmia (ATa) recurrences following a single procedure. Specifically, 72.8% of patients presenting with PAF and 59.1% of individuals with PersAF did not experience a recurrence. CONCLUSIONS: A single 3-min freeze per vein strategy is effective in treating AF on a long term follow-up of 38 months. Specifically, it can afford freedom from ATa recurrences in 72.8% of patients affected by PAF and 59.1% of patients initially presenting with PersAF after a single CB-A procedure.