Pulmonary Vein Isolation With and Without Posterior Wall Isolation in Paroxysmal Atrial Fibrillation: IMPPROVE-PAF Trial

Arash Aryana; Anna M Thiemann; Deep K Pujara; Laura L Cossette; Shelley L Allen; Mark R Bowers; Maheer Gandhavadi; Russell Heath; Amar D Trivedi; Padraig Gearoid O'Neill; Ethan R Ellis; André d'Avila

doi:10.1016/j.jacep.2023.01.014

Pulmonary Vein Isolation With and Without Posterior Wall Isolation in Paroxysmal Atrial Fibrillation: IMPPROVE-PAF Trial

JACC Clin Electrophysiol. 2023 May;9(5):628-637. doi: 10.1016/j.jacep.2023.01.014. Epub 2023 Mar 22.

Authors

Affiliations

¹ Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA. Electronic address: a_aryana@outlook.com.
² California Northstate University College of Medicine, Elk Grove, California, USA.
³ University of Texas Health Science Center at Houston, Houston, Texas, USA.
⁴ Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA.
⁵ Overlake Hospital Medical Center, Bellevue, Washington, USA.
⁶ University of Colorado Health, Fort Collins, Colorado, USA.
⁷ Harvard Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

PMID: 37225309
DOI: 10.1016/j.jacep.2023.01.014

Abstract

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). PVI+PWI 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 = 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 PVI+PWI appears to be associated with greater freedom from recurrent atrial arrhythmias and AF in patients with PAF during long-term follow-up >3 years.

Keywords: catheter ablation; cryoballoon; paroxysmal atrial fibrillation; posterior wall isolation; pulmonary vein isolation.

MeSH terms

Atrial Fibrillation* / surgery
Catheter Ablation* / adverse effects
Cryosurgery* / adverse effects
Humans
Pulmonary Veins* / surgery
Retrospective Studies

Associated data

ClinicalTrials.gov/NCT05296824