Pulmonary Vein Isolation for AF RF or Cryo? Dr. Yuen Ho Chuen Princess Margaret Hospital

PV as a Source of Ectopic Activity Haissaguerre, et al. NEJM 1998

RF Ablation Gold standard Point by point ablation Largest experience worldwide

Cryoballoon Young technology Single shot approach Fast learning curve Aim: ablation faster and safer

Ideal AF Ablation Procedure Efficacy Safety Durability Ease of use

Meta-analysis of AF RF Ablation Ganesan, et al. J Am Heart Assoc2013

Outcomes of AF RF Ablation: 2 nd Worldwide Survey Cappato, et al. CircA&E 2010

Long-term Results for RF University of Pennsylvania Free from AF 1 year after ablation 123 patients ~7%/year late recurrence rate after the 1 st year Tzou, et al. CircA&E 2010

Long-term Results for RF Tzou, et al. CircA&E 2010

Very Long-term Results for RF New York, single centre Free from AF 1 year post-ablation (single procedure in 391 (87.9%)) 445 patients AF recurrence: 16.3% and 29.8% at 5 and 10 years respectively Steinberg, et al. HR 2014

Cryothermic Lesion Characteristics Less endothelial disruption than RF, thus less thrombus formation Smaller than RF lesions Dense, homogenous fibrosis Well demarcated border zone Underlying cellular matrix & tensile strength preserved Khairy, et al. Circulation 2003

Meta-analysis of AF Cryoballoon Ablation Andrade, et al. HR 2011

Long-term Results for Cryoballoon Germany, single centre, prospective observational 605 patients (579 PAF) At median FU of 30 months, freedom from AF: 61.6% Need for focal touch-up in 9% 23-mm CB: 26.7%, 28-mm CB: 25.6%, both: 47.7% Vogt, et al. JACC 2013

Challenge to Cryoballoon Ablation: Left Common Pulmonary Vein

Need for Touch-up

Complications of AF Ablation RF Ablation: 2 nd Worldwide Survey Cryoballoon: Germany, single centre Cappato, et al. CircA&E 2010 Vogt, et al. JACC 2013

Complications of AF Ablation Andrade, et al. HR 2011

Asymptomatic Brain Lesions Wissner, et al. Europace 2014

Post AF Ablation AT Stockholm, single centre, retrospective 630 patients with PAF RF=415, CB=215 Mean FU : 38+/-21 months Akerstrom, et al. JCE 2014

RF vs Cryoballoon United Kingdom, single centre, non-randomized 143 patients with PAF CB=90; RF=53 Kojodjojo, et al. Heart 2010

RF vs Cryoballoon Kojodjojo, et al. Heart 2010

RF vs Cryoballoon Belgium, single centre, retrospective 396 patients with PAF RF=260, CB=136 At mean FU 23+/-13 months, FFAF rates: 57.3% in RF vs 63.2% in CB (p=0.25) Mugnai, et at. Am J Cardiol2014

RF vs Cryoballoon Mugnai, et at. Am J Cardiol2014

RF vs Cryoballoon Cryoballoon Mugnai, et at. Am J Cardiol2014

Learning Curve for Cryoballoon Vogt, et al. JACC 2013

Germany Ablation Registry March 2007 - September 2011 2256 consecutive patients with PAF 55 centres CB=604 (26.8%), RF=1652 (73.2%) Schmidt, et al. JCE 2014

Germany Ablation Registry Longer ablation time due to lack of experience for cryoballoon in early stage? Schmidt, et al. JCE 2014

Germany Ablation Registry Schmidt, et al. JCE 2014

FreezeAF Germany, single centre, randomized 315 patients with PAF CB=156, RF=159 Redo procedures were permitted between 6 and 12 months using only the original energy source FFAF rates: At 6 months: 63% in CB vs 64% in RF At 12 months: 68% in CB vs 65% in RF Complication rates were significantly higher in CB group (driven by 5.1% PNP which all recovered within 12 months) Luik, et al. HRS 2015 Late-Breaking Session

Phrenic Nerve Monitoring by CMAP Franceschi, et al. HR 2011

2 nd Generation Cryoballoon

Reduction in Need for Touch-up Study Packer, et al JACC 2013 with 2 nd Gen CB PVI by CB only Noof CB applications 83% Mean 12.5 per patient Sizeof CB used CB generation Both sizes: 20.8% of PV 1st Chun, et al EHJ 2009 92% >4 per vein in 44% 28mm only 1st Kojodjojo, et al Heart 2010 40% Limit 2 per vein 28mm only 1st Straube, et al Circ A&E 2014 100% Mean 2.82 per vein Mean 11.6 per patient Bothsizes: 21% 2nd

1 st Gen CB vs 2 nd Gen CB (With a 3-month blanking) Belgium, single centre, nonrandomized 100 patients with PAF 50 CB1 vs 50 CB2 12-month FU AF-free survival: CB1 66% vs CB2 84% (with a 3-month blanking) (p=0.038) Di Giovani, et al. JCE 2014

Efficacy of 2 nd Gen CB Freedom from AF at 1 year; Single centre studies; No AADs

Higher incidence of PNP with 2 nd Gen CB Prospective observational study in a single centre in Belgium 1 st gen CB compared with 2 nd gen CB 1 st gen CB: 80 patients (Group 1) 2 nd gen CB: 41 patients (Group 2) Evaluated incidence of phrenic nerve paralysis PNP occurred in 13 (10.7%) of patients 5/80 (6.25%) in Group 1 vs 8/41 (19.5%) in Group 2 (p=0.033) At 7 months, PNP persisted in only 1 patient (2.5%) in Group 2 Casado-Arroyo, et al. HR 2013

Atrioesophageal Fistula with 2 nd Gen CB 3 patients in 3 different institutes in US 1 st gen CB in 1 patient and 2 nd gen CB in 2 patients All used 28mm balloon 1 patient had LET which recorded <20 C at LIPV ablation 2 patients underwent surgical repair All died Kawasaki, et al. JCE 2014

RF vs 2 nd Gen CB US, multicentre, non-randomized 1196 patients with AF (76% paroxysmal AF) 2 nd gen CB=773, RF=423 In CB group, only 1.6% PVs needed RF touch-up 1-year FFAF rates for paroxysmal AF: 78.4% in 2 nd gen CB vs 60.8% in RF (p<0.001) Aryana, et al. JCE 2015

RF vs 2 nd Gen CB Proceduraldata RF 2 nd Gen CB P value Ablation time (min) 66+/-26 40+/-14 <0.001 Procedural time (min) 188+/-42 145+/-49 <0.001 Fluoroscopic time (min) 23+/-14 29+/-13 <0.001 Complications RF 2 nd Gen CB P value Transient PNP 0% 7.6% <0.001 Persistent PNP 0% 1.2% 0.026 Other adverse events 2.6% 1.6% 0.207 FU RF 2 nd Gen CB P value Re-do ablation 24.1% 14.6% NA Patients with PV reconnection at redo ablation 65.7% 44.2% 0.002 Aryana, et al. JCE 2015

Durability of PVI by 2 nd Gen CB Czech Republic 21 patients with PAF Ablated with 2 nd gen CB Remapped at 3 months 90% of PVs showed durable PVI (lowest 83% in RIPV, mostly inferior border) Reddy, et al. JCE 2015

Contact Force Technologies TactiCath, St. Jude Medical SmartTouch, Biosense Webster

Durability of PVI by CF 3 centre study EFFICAS I: Operator blinded to contact force information EFFICAS II: Operator NOT blinded & actively using contact force at ablation Neuzil, et al. CircA&E 2013

Improved Durable PVI by CF (26 patients) (24 patients) Kautzner, et al. Europace 2015

CF guided RF Montreal, non-randomized 75 patients with PAF SmartTouch=25, control=50 After PVI, adenosine testing for dormant PV conduction 1-year FFAF rates: CFguided group 88% vs control group 66% (p=0.047) Andrade, et al. HR 2014

CF-guided RF vs 2 nd Gen CB France, single centre, nonrandomized 150 patients with PAF Smart touch=75, 2 nd gen CB=75 In RF group, mean CF: 19.7g In CB group, PVI was achieved without touch-up in 100% patients, persistent PNP 0% Jourda, et al. Europace 2015

Conclusions Outcomes are comparable between RF and cryoballoon ablation for AF Cryoballoon ablation is associated with higher incidence of PNP but may cause less cardiac tamponade Cryoballoon ablation may be faster than RF ablation 2 nd Gen CB and CF-guided RF ablation are promising technologies which may improve outcomes of AF ablation