Pulmonary Vein Isolation With and Without Posterior Wall Isolation in Paroxysmal Atrial Fibrillation

BACKGROUND Prior studies have demonstrated clinical benefits associated with cryoballoon pulmonary vein isolation (PVI) and concomitant posterior wall isolation (PWI) in patients with persistent atrial fibrillation (AF). However, the role for this approach in patients with paroxysmal atrial fibrillation (PAF) remains unclear. OBJECTIVES This study investigated the acute and long-term outcomes of PVI vs PVI+PWI using cryoballoon in patients with symptomatic PAF. METHODS This retrospective study (NCT05296824) examined the outcomes of cryoballoon PVI (n = 1,342) vs cryoballoon PVI+PWI (n = 442) in patients with symptomatic PAF during long-term follow-up. Using the nearest-neighbor method, a 1:1 matched sample of patients receiving PVI alone and PVI+PWI was created. RESULTS The matched cohort consisted of 320 patients (PVI: n = 160; PVI+PWI: n = 160). PVIthornPWI was associated with longer cryoablation (23 +/- 10 minutes vs 42 +/- 11 minutes; P < 0.001) and procedure times (103 +/- 24 minutes vs 127 +/- 14 minutes; P < 0.001). In 39 (24.4%) of 160 patients, adjunct radiofrequency ablation was required for PVI+PWI. Adverse event rates were similar (PVI 3.8% vs PVI+PWI 1.9%; P 1/4 0.31). Though there were no differences at 12 months, freedom from all atrial arrhythmias (67.5% vs 45.0%; P < 0.001) and AF (75.6% vs 55.0%; P < 0.001) were significantly greater with PVI+PWI vs PVI alone at 39 +/- 9 months of follow-up. PVI+PWI was also associated with reduced long-term need for cardioversion (16.9% vs 27.5%; P = 0.02) and repeat catheter ablation (11.9% vs 26.3%; P = 0.001), and emerged as the only significant predictor of freedom from recurrent AF (HR: 2.79; 95% CI: 1.64-4.74; P < 0.001). CONCLUSIONS Compared with cryoballoon PVI, cryoballoon PVIthornPWI appears to be associated with greater freedom from recurrent atrial arrhythmias and AF in patients with PAF during long-term follow-up >3 years. (J Am Coll Cardiol EP 2023;9:628-637) (c) 2023 by the American College of Cardiology Foundation.

Automated summary

This study investigated the acute and long-term outcomes of cryoballoon PVI vs PVI+PWI in patients with symptomatic PAF. The results showed that PVI+PWI treatment was associated with greater freedom from recurrent atrial arrhythmias and AF during long-term follow-up, compared to PVI alone.