Abstract
Background: Ablation therapy is the treatment of choice in antiarrhythmic drugrefractory atrial fibrillation (AF). It is performed by either cryoballoon ablation (CBA) or radiofrequency ablation. CBA is gaining popularity due to simplicity with similar efficacy and complication rate compared with RFA. In this meta-analysis, we compare the recurrence rate of AF and the complications from CBA versus RFA for the treatment of AF.
Methods: We systematically searched PubMed for the articles that compared the outcome of interest. The primary outcome was to compare the recurrence rate of AF between CBA and RFA. We also included subgroup analysis with complications of pericardial effusion, phrenic nerve palsy and cerebral microemboli following ablation therapy.
Results: A total of 24 studies with 3527 patients met our predefined inclusion criteria. Recurrence of AF after CBA or RFA was similar in both groups (RR: 0.84; 95% CI: 0.65, 1.07; I2=48%, Cochrane p=0.16). In subgroup analysis, heterogeneity was less in paroxysmal AF (I2=0%, Cochrane p=0.46) compared to mixed AF (I2=72%, Cochrane p=0.003). Procedure and fluoroscopy time was less by 26.37 and 5.94 minutes respectively in CBA compared to RFA. Complications, pericardial effusion, and silent cerebral microemboli, were not different between the two groups, however, phrenic nerve palsy was exclusively present only in CBA group.
Conclusion: This study confirms that the effectiveness of CBA is similar to RFA in the treatment of AF with the added advantages of shorter procedure and fluoroscopy times.
Keywords: Atrial fibrillation, cryoballoon ablation, meta-analysis, pericardial effusion, phrenic nerve palsy, radiofrequency ablation, silent cerebral microemboli.
Graphical Abstract
[1]
Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemiology of atrial fibrillation: A Global Burden of Disease 2010 Study. Circulation 2014; 129: 837-47.
[2]
Calkins H, Kuck KH, Cappato R, et al. Heart Rhythm Society Task
Force on C and Surgical Ablation of Atrial F. 2012
HRS/EHRA/ECAS expert consensus statement on catheter and
surgical ablation of atrial fibrillation: Recommendations for patient
selection, procedural techniques, patient management and followup,
definitions, endpoints, and research trial design: A report of the
Heart Rhythm Society (HRS) Task Force on Catheter and Surgical
Ablation of Atrial Fibrillation. Developed in partnership with the
European Heart Rhythm Association (EHRA), a registered branch
of the European Society of Cardiology (ESC) and the European
Cardiac Arrhythmia Society (ECAS); and in collaboration with the
American College of Cardiology (ACC), American Heart
Association (AHA), the Asia Pacific Heart Rhythm Society
(APHRS), and the Society of Thoracic Surgeons (STS). Endorsed
by the governing bodies of the American College of Cardiology
Foundation, the American Heart Association, the European Cardiac
Arrhythmia Society, the European Heart Rhythm Association, the
Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm
Society, and the Heart Rhythm Society. Heart Rhythm 2012; 9: 632-96. e21.
[3]
Ciconte G, Baltogiannis G, de Asmundis C, et al. Circumferential pulmonary vein isolation as index procedure for persistent atrial fibrillation: a comparison between radiofrequency catheter ablation and second-generation cryoballoon ablation. Europace 2015; 17: 559-65.
[4]
Pratola C, Baldo E, Notarstefano P, Toselli T, Ferrari R. Radiofrequency ablation of atrial fibrillation: is the persistence of all intraprocedural targets necessary for long-term maintenance of sinus rhythm? Circulation 2008; 117: 136-43.
[5]
Georgiopoulos G, Tsiachris D, Manolis AS. Cryoballoon ablation of atrial fibrillation: A practical and effective approach. Clin Cardiol 2017; 40: 333-42.
[6]
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. J Clin Epidemiol 2009; 62: 1006-12.
[7]
Leblais V, Delannoy E, Fresquet F, et al. Beta-adrenergic relaxation in pulmonary arteries: Preservation of the endothelial nitric oxide-dependent beta2 component in pulmonary hypertension. Cardiovasc Res 2008; 77: 202-10.
[8]
Linhart M, Bellmann B, Mittmann-Braun E, et al. Comparison of cryoballoon and radiofrequency ablation of pulmonary veins in 40 patients with paroxysmal atrial fibrillation: A case-control study. J Cardiovasc Electrophysiol 2009; 20: 1343-8.
[9]
Sauren LD, Vanb Y, Der L, et al. Transcranial measurement of cerebral microembolic signals during endocardial pulmonary vein isolation: Comparison of three different ablation techniques. J Cardiovasc Electrophysiol 2009; 20: 1102-7.
[10]
Chierchia GB, Capulzini L, Droogmans S, et al. Pericardial effusion in atrial fibrillation ablation: A comparison between cryoballoon and radiofrequency pulmonary vein isolation. Europace 2010; 12: 337-41.
[11]
Kojodjojo P, O’Neill MD, Lim PB, et al. Pulmonary venous isolation by antral ablation with a large cryoballoon for treatment of paroxysmal and persistent atrial fibrillation: Medium-term outcomes and non-randomised comparison with pulmonary venous isolation by radiofrequency ablation. Heart 2010; 96: 1379-84.
[12]
Kuhne M, Suter Y, Altmann D, et al. Cryoballoon versus radiofrequency catheter ablation of paroxysmal atrial fibrillation: Biomarkers of myocardial injury, recurrence rates, and pulmonary vein reconnection patterns. Heart Rhythm 2010; 7: 1770-6.
[13]
Sorgente A, Chierchia GB, de Asmundis C, Capulzini L, Sarkozy A, Brugada P. Cryoballoon ablation of atrial fibrillation: State of the art 10 years after its invention. Recent Pat Cardiovasc Drug Discov 2010; 5: 177-83.
[14]
Gaita F, Leclercq JF, Schumacher B, et al. Incidence of silent cerebral thromboembolic lesions after atrial fibrillation ablation may change according to technology used: Comparison of irrigated radiofrequency, multipolar nonirrigated catheter and cryoballoon. J Cardiovasc Electrophysiol 2011; 22: 961-8.
[15]
Herrera Siklody C, Deneke T, Hocini M, et al. Incidence of asymptomatic intracranial embolic events after pulmonary vein isolation: Comparison of different atrial fibrillation ablation technologies in a multicenter study. J Am Coll Cardiol 2011; 58: 681-8.
[16]
Neumann T, Kuniss M, Conradi G, et al. MEDAFI-Trial (Micro-embolization during ablation of atrial fibrillation): Comparison of pulmonary vein isolation using cryoballoon technique vs. radiofrequency energy. Europace 2011; 13: 37-44.
[17]
Herrera Siklody C, Arentz T, Minners J, et al. Cellular damage, platelet activation, and inflammatory response after pulmonary vein isolation: A randomized study comparing radiofrequency ablation with cryoablation. Heart Rhythm 2012; 9: 189-96.
[18]
Schmidt M, Dorwarth U, Straube F, et al. A novel double cryoballoon strategy in persistent atrial fibrillation: A pilot study. Clin Res Cardiol 2012; 101: 777-85.
[19]
Maagh P, Butz T, Plehn G, Christoph A, Meissner A. Pulmonary vein isolation in 2012: Is it necessary to perform a time consuming electrophysical mapping or should we focus on rapid and safe therapies? A retrospective analysis of different ablation tools. Int J Med Sci 2013; 10: 24-33.
[20]
Malmborg H, Christersson C, Lonnerholm S, Blomstrom-Lundqvist C. Comparison of effects on coagulation and inflammatory markers using a duty-cycled bipolar and unipolar radiofrequency pulmonary vein ablation catheter vs. a cryoballoon catheter for pulmonary vein isolation. Europace 2013; 15: 798-804.
[21]
Schmidt M, Dorwarth U, Straube F, et al. Cryoballoon in AF ablation: Impact of PV ovality on AF recurrence. Int J Cardiol 2013; 167: 114-20.
[22]
Mugnai G, Chierchia GB, de Asmundis C, et al. Comparison of pulmonary vein isolation using cryoballoon versus conventional radiofrequency for paroxysmal atrial fibrillation. Am J Cardiol 2014; 113: 1509-13.
[23]
Perez-Castellano N, Fernandez-Cavazos R, Moreno J, et al. The COR trial: A randomized study with continuous rhythm monitoring to compare the efficacy of cryoenergy and radiofrequency for pulmonary vein isolation. Heart Rhythm 2014; 11: 8-14.
[24]
Hunter RJ, Baker V, Finlay MC, et al. Point-by-point radiofrequency ablation versus the cryoballoon or a novel combined approach: A randomized trial comparing 3 methods of pulmonary vein isolation for paroxysmal atrial fibrillation (The Cryo Versus RF Trial). J Cardiovasc Electrophysiol 2015; 26: 1307-14.
[25]
Jourda F, Providencia R, Marijon E, et al. Contact-force guided radiofrequency vs. second-generation balloon cryotherapy for pulmonary vein isolation in patients with paroxysmal atrial fibrillation-a prospective evaluation. Europace 2015; 17: 225-31.
[26]
Luik A, Radzewitz A, Kieser M, et al. Cryoballoon versus open irrigated radiofrequency ablation in patients with paroxysmal atrial fibrillation: the prospective, randomized, controlled, noninferiority freezeAF study. Circulation 2015; 132: 1311-9.
[27]
Wasserlauf J, Pelchovitz DJ, Rhyner J, et al. Cryoballoon versus radiofrequency catheter ablation for paroxysmal atrial fibrillation. Pacing Clin Electrophysiol 2015; 38: 483-9.
[28]
Kuck KH, Brugada J, Furnkranz A, et al. Investigators ICE. Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation. N Engl J Med 2016; 374: 2235-45.
[29]
Yokokawa M, Chugh A, Latchamsetty R, et al. Ablation of paroxysmal atrial fibrillation using a second-generation cryoballoon catheter or contact-force sensing radiofrequency ablation catheter: A comparison of costs and long-term clinical outcomes. J Cardiovasc Electrophysiol 2018; 29: 284-90.
[30]
Matta M, Anselmino M, Ferraris F, Scaglione M, Gaita F. Cryoballoon vs. radiofrequency contact force ablation for paroxysmal atrial fibrillation: A propensity score analysis. J Cardiovasc Med (Hagerstown) 2018; 19: 141-7.
[31]
Khairy P, Chauvet P, Lehmann J, et al. Lower incidence of thrombus formation with cryoenergy versus radiofrequency catheter ablation. Circulation 2003; 107: 2045-50.
[32]
Sarabanda AV, Bunch TJ, Johnson SB, et al. Efficacy and safety of circumferential pulmonary vein isolation using a novel cryothermal balloon ablation system. J Am Coll Cardiol 2005; 46: 1902-12.
[33]
Knecht S, Sticherling C, von Felten S, et al. Long-term comparison of cryoballoon and radiofrequency ablation of paroxysmal atrial fibrillation: A propensity score matched analysis. Int J Cardiol 2014; 176: 645-50.
[34]
Aryana A, Kowalski M, O’Neill PG, et al. Catheter ablation using the third-generation cryoballoon provides an enhanced ability to assess time to pulmonary vein isolation facilitating the ablation strategy: Short- and long-term results of a multicenter study. Heart Rhythm 2016; 13: 2306-13.
[35]
Packer DL, Kowal RC, Wheelan KR, et al. Investigators SAC. Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: First results of the North American Arctic Front (STOP AF) pivotal trial. J Am Coll Cardiol 2013; 61: 1713-23.
[36]
Van Belle Y, Jordaens L. Reflections on reconduction after pulmonary vein isolation. Europace 2009; 11: 400-1.
[37]
Schaer B, Kuhne M, Koller MT, Sticherling C, Osswald S. Therapy with an implantable cardioverter defibrillator (ICD) in patients with coronary artery disease and dilated cardiomyopathy: Benefits and disadvantages. Swiss Med Wkly 2009; 139: 647-53.
[38]
Petersen P, Madsen EB, Brun B, Pedersen F, Gyldensted C, Boysen G. Silent cerebral infarction in chronic atrial fibrillation. Stroke 1987; 18: 1098-100.
[39]
Epstein MR, Knapp LD, Martindill M, et al. Embolic complications associated with radiofrequency catheter ablation. Atakr Investigator Group. Am J Cardiol 1996; 77: 655-8.
[40]
Kawasaki R, Gauri A, Elmouchi D, Duggal M, Bhan A. Atrioesophageal fistula complicating cryoballoon pulmonary vein isolation for paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2014; 25: 787-92.
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