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  • 1.
    Blomström-Lundqvist, Carina
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Gizurarson, Sigfus
    Univ Gothenburg, Sahlgrenska Acad, Dept Mol & Clin Med Cardiol, Inst Med, Gothenburg, Sweden;Sahlgrens Univ Hosp, Dept Cardiol, Gothenburg, Sweden.
    Schwieler, Jonas
    Karolinska Univ Hosp, Heart & Vasc Theme, Stockholm, Sweden.
    Jensen, Steen M
    Umea Univ, Ctr Heart, Umea, Sweden;Umea Univ, Dept Publ Hlth & Clin Med, Umea, Sweden.
    Bergfeldt, Lennart
    Univ Gothenburg, Sahlgrenska Acad, Dept Mol & Clin Med Cardiol, Inst Med, Gothenburg, Sweden;Sahlgrens Univ Hosp, Dept Cardiol, Gothenburg, Sweden.
    Kennebäck, Göran
    Karolinska Univ Hosp, Heart & Vasc Theme, Stockholm, Sweden.
    Rubulis, Aigars
    Univ Gothenburg, Sahlgrenska Acad, Dept Mol & Clin Med Cardiol, Inst Med, Gothenburg, Sweden;Sahlgrens Univ Hosp, Dept Cardiol, Gothenburg, Sweden.
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Raatikainen, Pekka
    Tampere Univ Hosp, Dept Cardiol, Ctr Heart, Tampere, Finland.
    Lönnerholm, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Höglund, Niklas
    Umea Univ, Ctr Heart, Umea, Sweden;Umea Univ, Dept Publ Hlth & Clin Med, Umea, Sweden.
    Mörtsell, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Effect of Catheter Ablation vs Antiarrhythmic Medication on Quality of Life in Patients With Atrial Fibrillation: The CAPTAF Randomized Clinical Trial2019In: JAMIA Journal of the American Medical Informatics Association, ISSN 1067-5027, E-ISSN 1527-974X, Vol. 321, no 11, p. 1059-1068Article in journal (Refereed)
    Abstract [en]

    IMPORTANCE Quality of life is not a standard primary outcome in ablation trials, even though symptoms drive the indication. OBJECTIVE To assess quality of life with catheter ablation vs antiarrhythmic medication at 12 months in patients with atrial fibrillation. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial at 4 university hospitals in Sweden and 1 in Finland of 155 patients aged 30-70 years with more than 6 months of atrial fibrillation and treatment failure with 1 antiarrhythmic drug or beta-blocker, with 4-year follow-up. Study dateswere July 2008-September 2017. Major exclusionswere ejection fraction <35%, left atrial diameter > 60 mm, ventricular pacing dependency, and previous ablation. INTERVENTIONS Pulmonary vein isolation ablation (n= 79) or previously untested antiarrhythmic drugs (n= 76). MAIN OUTCOMES AND MEASURES Primary outcomewas the General Health subscale score (Medical Outcomes Study 36-Item Short-Form Health Survey) at baseline and 12 months, assessed unblinded (range, 0 [worst] to 100 [best]). There were 26 secondary outcomes, including atrial fibrillation burden (% of time) from baseline to 12 months, measured by implantable cardiac monitors. The first 3 months were excluded from rhythm analysis. RESULTS Among 155 randomized patients (mean age, 56.1 years; 22.6% women), 97% completed the trial. Of 79 patients randomized to receive ablation, 75 underwent ablation, including 2 who crossed over to medication and 14 who underwent repeated ablation procedures. Of 76 patients randomized to receive antiarrhythmic medication, 74 received it, including 8 who crossed over to ablation and 43 for whom the first drug used failed. General Health score increased from 61.8 to 73.9 points in the ablation group vs 62.7 to 65.4 points in the medication group (between-group difference, 8.9 points; 95% CI, 3.1-14.7; P=.003). Of 26 secondary end points, 5 were analyzed; 2 were null and 2 were statistically significant, including decrease in atrial fibrillation burden (from 24.9% to 5.5% in the ablation group vs 23.3% to 11.5% in the medication group; difference -6.8%[95% CI, -12.9% to -0.7%]; P=.03). Of the Health Survey subscales, 5 of 7 improved significantly. Most common adverse events were urosepsis (5.1%) in the ablation group and atrial tachycardia (3.9%) in the medication group. CONCLUSIONS AND RELEVANCE Among patients with symptomatic atrial fibrillation despite use of antiarrhythmic medication, the improvement in quality of life at 12 months was greater for those treated with catheter ablation compared with antiarrhythmic medication. Although the study was limited by absence of blinding, catheter ablation may offer an advantage for quality of life.

  • 2.
    Blomström-Lundqvist, Carina
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology.
    Potpara, Tatjana S
    Univ Belgrade, Sch Med, Belgrade, Serbia.
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Supraventricular Arrhythmias in Patients with Adult Congenital Heart Disease.2017In: Arrhythmia & electrophysiology review, ISSN 2050-3369, Vol. 6, no 2, p. 42-49Article in journal (Refereed)
    Abstract [en]

    An increasing number of patients with congenital heart disease survive to adulthood; such prolonged survival is related to a rapid evolution of successful surgical repairs and modern diagnostic techniques. Despite these improvements, corrective atrial incisions performed at surgery still lead to subsequent myocardial scarring harbouring a potential substrate for macro-reentrant atrial tachycardia. Macroreentrant atrial tachycardias are the most common (75 %) type of supraventricular tachycardia (SVT) in patients with adult congenital heart disease (ACHD). Patients with ACHD, atrial tachycardias and impaired ventricular function - important risk factors for sudden cardiac death (SCD) - have a 2-9 % SCD risk per decade. Moreover, ACHD imposes certain considerations when choosing antiarrhythmic drugs from a safety aspect and also when considering catheter ablation procedures related to the inherent cardiac anatomical barriers and required expertise. Expert recommendations for physicians managing these patients are therefore mandatory. This review summarises current evidence-based developments in the field, focusing on advances in and general recommendations for the management of ACHD, including the recently published recommendations on management of SVT by the European Heart Rhythm Association.

  • 3.
    Katritsis, Demosthenes G
    et al.
    Athens Euroclinic, Athens, Greece; and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
    Boriani, Giuseppe
    Cardiology Department, Modena University Hospital, University of Modena and Reggio Emilia, Modena, Italy.
    Cosio, Francisco G
    Hospital Universitario De Getafe, Madrid, Spain.
    Hindricks, Gerhard
    University of Leipzig, Heartcenter, Leipzig, Germany.
    Jais, Pierre
    University of Bordeaux, CHU Bordeaux, LIRYC, France.
    Josephson, Mark E
    Berth Israel Deaconess Medical Center, Boston, MA, USA.
    Keegan, Roberto
    Hospital Privado del Sur y Hospital Español, Bahia Blanca, Argentina.
    Kim, Young-Hoon
    Korea University Medical Center, Seoul, Republic of Korea.
    Knight, Bradley P
    Northwestern Memorial Hospital, Chicago, IL, USA.
    Kuck, Karl-Heinz
    Asklepios Hospital St Georg, Hamburg, Germany.
    Lane, Deirdre A
    University of Birmingham Institute of Cardiovascular Science, City Hospital, Birmingham, UK; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
    Lip, Gregory Y H
    University of Birmingham Institute of Cardiovascular Science, City Hospital, Birmingham, UK; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Oral, Hakan
    University of Michigan, Ann Arbor, MI, USA.
    Pappone, Carlo
    IRCCS Policlinico San Donato, San Donato Milanese, Italy.
    Themistoclakis, Sakis
    Dell’Angelo Hosiptal, Venice-Mestre, Italy.
    Wood, Kathryn A
    Emory University School of Nursing, Atlanta, USA.
    Blomström-Lundqvist, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE)2018In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 39, no 16, p. 1442-1445, article id ehw455Article in journal (Refereed)
  • 4. Katritsis, Demosthenes G
    et al.
    Boriani, Giuseppe
    Cosio, Francisco G
    Hindricks, Gerhard
    Jaïs, Pierre
    Josephson, Mark E
    Keegan, Roberto
    Kim, Young-Hoon
    Knight, Bradley P
    Kuck, Karl-Heinz
    Lane, Deirdre A
    Lip, Gregory Y H
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Oral, Hakan
    Pappone, Carlo
    Themistoclakis, Sakis
    Wood, Kathryn A
    Blomström-Lundqvist, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Gorenek, Bulent
    Dagres, Nikolaos
    Dan, Gheorge-Andrei
    Vos, Marc A
    Kudaiberdieva, Gulmira
    Crijns, Harry
    Roberts-Thomson, Kurt
    Lin, Yenn-Jiang
    Vanegas, Diego
    Caorsi, Walter Reyes
    Cronin, Edmond
    Rickard, Jack
    European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE)2017In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 19, no 3, p. 465-511Article in journal (Refereed)
  • 5.
    Lönnerholm, Stefan
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Blomström, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Blomström- Lundqvist, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Efficacy and safety of different energy settings for atrial fibrillation ablation using the duty-cycled radiofrequency ablation catheter (PVAC)2014In: Journal of cardiovascular medicine and cardiology, Vol. 1, p. 102-Article in journal (Refereed)
    Abstract [sv]

    Catheter based pulmonary vein isolation (PVI), is the recommended therapy for drug-refractory atrial fibrillation (AF) [1]. The procedure may be technically challenging, can be time consuming and highly dependent on operators skill. In order to improve the efficacy of PV isolation, shorten the procedure time and learning curve of operators; new specially designed catheters for pulmonary vein isolation have been developed [2-4]. One of these catheters is the Pulmonary Vein Ablation Catheter (PVAC) (Medtronic; Minneapolis, USA), which is a 10-pole circular, over the wire catheter used in combination with a multi-channel, duty-cycled radiofrequency generator (GENius; Medtronic) [2]. The feasibility of the PVAC has been demonstrated in a number of studies and randomized clinical studies have reported similar clinical results compared to point-by-point ablation around the pulmonary veins [2,5-9]. The energy can be delivered in a unipolar or bipolar setting or combined in various ratios. A higher proportion of unipolar energy will give deeper lesions but less energy between the poles possibly leading to non-continuous lines [12]. Although certain energy settings have been recommended for PV isolation there are no randomized studies that have compared the different settings for this purpose. The aim of this study was therefore to compare the efficacy and safety of PV isolation using a 4:1 versus a 2:1 unipolar/bipolar energy setting with the PVAC. Our hypothesis was that the 2:1 setting, delivering more unipolar energy, would result in deeper and more transmural lesions for pulmonary vein isolation leading to fewer applications and thus shorter procedure times.

  • 6.
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Catheter Ablation of Atrial Fibrillation and Atrial Flutter: A Comparison of Cryo and Radiofrequency Techniques2014Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Atrial fibrillation (AF) and atrial flutter (AFl) are two of the most common arrhythmias encountered in the population. Catheter ablation has emerged as a useful tool in the treatment of these arrhythmias. Although radiofrequency (RF) is the most commonly used energy source for ablation, cryoenergy may have some advantageous properties. The purpose of these studies was to evaluate and compare ablation with novel ablation catheters using either of these energy sources.

    When used for AFl ablation, cryoenergy was associated with less perceived pain than radiofrequency. However, the acute success rate was significantly lower for cryoablation (56%) compared with RF ablation (100%) in our study.

    Being one of the first centres to use a new so-called “one-shot” device for pulmonary vein isolation (PVI), the cryoballoon, we described our initial experience with this catheter in 40 patients undergoing AF ablation.  A high rate of PVI could be achieved although an additional cryocatheter was needed in 44% of the procedures. Freedom from arrhythmia-related symptoms was seen in 53% after a mean follow-up of 8.9 months.

    Comparing the cryoballoon and a RF-based device intended for PVI, the pulmonary vein ablation catheter (PVAC), both catheters proved comparably effective (≥93%) and safe in achieving PVI with comparable procedure times. After 12 months only 46% versus 34% (ns) in the cryoballoon- and the PVAC group, respectively, were regarded as free from AF without antiarrhythmic drugs, after one ablation procedure, whereas 60% versus 54% reported clinical success. Quality of life was significantly increased in both groups, to a level comparable with the general Swedish population.

    We tested the hypothesis that RF ablation would be accompanied by a higher activation of the coagulation and inflammatory systems, measured by biomarkers. Such a difference could not be supported in our study, which showed a comparable response with either technique, even though the cryoballoon caused more pronounced myocardial damage.

    Two different energy settings with different ratios of bipolar-to-unipolar energy were tested with the PVAC under the hypothesis that ablation with a higher proportion of unipolar energy would require fewer applications in order to achieve PVI. However, this study failed to show any difference between the groups.

  • 7.
    Malmborg, Helena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Christersson, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology.
    Lönnerholm, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Blomström-Lundqvist, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    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 isolation2013In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 15, no 6, p. 798-804Article in journal (Refereed)
    Abstract [en]

    AIMS:

    Thrombo-embolic events are one of the most feared complications related to atrial fibrillation (AF) ablation. Since radiofrequency (RF) energy is thought to be associated with a higher risk of thrombus formation than cryoenergy, the purpose of this study was to assess if the degree of activation of coagulation and inflammatory markers differed between ablation procedures performed with a cryoballoon catheter vs. a RF energy-based pulmonary vein ablation catheter (PVAC), respectively.

    METHODS AND RESULTS:

    Thirty patients referred for AF ablation were randomized to pulmonary vein isolation with either the cryoballoon or the PVAC. Biomarkers were studied for endothelial damage (von Willebrand factor antigen), platelet activation (soluble P-selectin), and coagulation activity [prothrombin fragment 1 + 2 (F1 + 2) and D-dimer] at five different time points during the procedure. Troponin I (Trop I) and C-reactive protein were analysed to reflect myocardial destruction and inflammatory activity. Markers of endothelial damage and platelet activation increased after ablation in both the cryo and the RF group. Similarly, the D-dimer levels increased significantly (P = 0.001) in both groups, whereas the F1 + 2 levels increased after the transseptal puncture only (P = 0.001). The overall activation of the coagulation system was, however, comparable between the groups. The cryoballoon was associated with higher Trop I compared with the PVAC (P < 0.001), but the ratios between biomarkers and Trop I were higher with the PVAC than with the cryoballoon.

    CONCLUSION:

    Even though the cryoballoon causes a higher degree of myocardial destruction than the PVAC, markers of coagulation, endothelial damage, and inflammation were comparable between the two techniques.

  • 8.
    Malmborg, Helena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Lönnerholm, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Blomström, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Blomström-Lundqvist, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Ablation of atrial fibrillation with cryoballoon or duty-cycled radiofrequency pulmonary vein ablation catheter: a randomized controlled study comparing the clinical outcome and safety; the AF-COR study2013In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 15, no 11, p. 1567-1573Article in journal (Refereed)
    Abstract [en]

    AIMS:

    The urge to facilitate the atrial fibrillation (AF) ablation procedure has led to the development of new ablation catheters specifically designed as 'one-shot tools' for pulmonary vein isolation (PVI). The purpose of this study was to compare the efficacy, safety, and procedure times for two such catheters using different energy sources.

    METHODS AND RESULTS:

    One hundred and ten patients, referred for ablation of paroxysmal or persistent AF, were randomized to treatment with either the cryoballoon or the circular multipolar duty-cycled radiofrequency-based pulmonary vein ablation catheter (PVAC). Complete PVI was achieved in 98 vs. 93% patients in the cryoballoon and PVAC group, respectively, with complication rates of 8 vs. 2% (P = 0.2). Complete freedom from AF, without antiarrhythmic drugs, after one single ablation procedure was seen in 46% in the cryoballoon vs. 34% after 12 months (P = 0.2). Procedure times were comparable, but fluoroscopy time was shorter for the cryoballoon (32 ± 16 min) than for the PVAC procedures (47 ± 17 min) (P < 0.001). A significant improvement of quality of life (QoL) and arrhythmia-related symptoms was seen in both groups after ablation.

    CONCLUSION:

    Both catheters proved comparably effective and safe in achieving acute PVI, apart from the shorter fluoroscopy times achieved with the cryoballoon. At follow-up, there was no statistically significant difference between the groups regarding freedom from AF and clinical success. The QoL increased to the same levels as for the general Swedish population in both groups.

  • 9.
    Maurer, T.
    et al.
    Asklepios Klin St Georg, Dept Cardiol, Lohmuhlenstr 5, Hamburg, Germany..
    Blomström-Lundqvist, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Tilz, R.
    Univ Hosp Schleswig Holstein, Dept Cardiol, Lubeck, Germany..
    Mont, L.
    Univ Barcelona, Hosp Clin, Thorax Inst, Barcelona, Spain..
    Chierchia, G-B
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Metzner, A.
    Asklepios Klin St Georg, Dept Cardiol, Lohmuhlenstr 5, Hamburg, Germany..
    Kuck, K-H
    What have we learned of ablation procedures for atrial fibrillation?2016In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 279, no 5, p. 439-448Article, review/survey (Refereed)
    Abstract [en]

    Atrial fibrillation is a widespread disease of growing clinical, economic and social importance. Interventional therapy for atrial fibrillation offers encouraging results, with pulmonary vein isolation (PVI) as the established cornerstone. Yet, the challenge to create durable transmural lesions remains, leading to recurrence of atrial fibrillation in long-term follow-up even after multiple ablation procedures in 20% of patients with paroxysmal atrial fibrillation and approximately 50% with persistent atrial fibrillation. To overcome these limitations, innovative tools such as the cryoballoon and contact force catheters have been introduced and have demonstrated their potential for safe and effective PVI. Furthermore, advanced pharmacological and pacing manoeuvres enhance evaluation of conduction block in PVI.

  • 10.
    Mörtsell, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Arbelo, Elena
    Dagres, Nikolaos
    Brugada, Josep
    Laroche, Cecile
    Trines, Serge A
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Höglund, Niklas
    Tavazzi, Luigi
    Pokushalov, Evgeny
    Stabile, Guiseppe
    Blomström-Lundqvist, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology.
    Cryoballoon versus radiofrequency ablation for atrial fibrillation – a study of outcome and safety based on the ESC-EHRA atrial fibrillation ablation long-term registry and the Swedish Catheter ablation registry2018In: Europace, ISSN 1099-5129, E-ISSN 1532-2092Article in journal (Refereed)
    Abstract [en]

    Aims

    Pulmonary vein isolation (PVI), the standard for atrial fibrillation (AF) ablation, is most commonly applied with radiofrequency (RF) energy, although cryoballoon technology (CRYO) has gained widespread use. The aim was to compare the second generation cryoballoon and the irrigated RF energy regarding outcomes and safety.

    Methods

    Of 4657 patients undergoing their first AF ablation, 982 with CRYO and 3675 with RF energy were included from the Swedish catheter ablation registry and the Atrial Fibrillation Ablation Long-Term registry of the European Heart Rhythm Association of the European Society of Cardiology. The primary endpoint was repeat AF ablation. The major secondary endpoints included procedural duration, tachyarrhythmia recurrence and complication rate.

    Results

    The re-ablation rate after 12 months was significantly lower in the CRYO versus the RF group, 7.8% versus 11%, p=0.005, while freedom from arrhythmia recurrence (30 seconds duration) did not differ between the groups, 70.2 % versus 68.2%, p=0.44. The result was not influenced by AF type and lesion sets applied. In Cox regression analysis for re-ablation paroxysmal AF had significantly lower risk with CRYO, hazard ratio 0.56 (p=0.041). Procedural duration was significantly shorter with CRYO than RF, (mean±SD) 133.6±45.2 minutes versus 174.6±58.2 minutes, p<0.001. Complication rates were similar; 53/982 (5.4%) versus 191/3675 (5.2%), CRYO versus RF, p=0.806.

    Conclusion

    The lower re-ablation rates and shorter procedure times observed with the cryoballoon compares favorably with RF ablation. Although there are inherent limitations with registries, our findings may have important clinical implications when choosing AF ablation technique.

  • 11.
    Mörtsell, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Arbelo, Elena
    Dagres, Nikolaos
    Brugada, Josep
    Laroche, Cécile
    Trines, Serge A
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Höglund, Niklas
    Tavazzi, Luigi
    Pokushalov, Evgeny
    Stabile, Giuseppe
    Blomström-Lundqvist, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology.
    Cryoballoon vs. radiofrequency ablation for atrial fibrillation: a study of outcome and safety based on the ESC-EHRA atrial fibrillation ablation long-term registry and the Swedish catheter ablation registry.2019In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 21, no 4, p. 581-589Article in journal (Refereed)
    Abstract [en]

    Aims: Pulmonary vein isolation (PVI), the standard for atrial fibrillation (AF) ablation, is most commonly applied with radiofrequency (RF) energy, although cryoballoon technology (CRYO) has gained widespread use. The aim was to compare the second-generation cryoballoon and the irrigated RF energy regarding outcomes and safety.

    Methods and results: Of 4657 patients undergoing their first AF ablation, 982 with CRYO and 3675 with RF energy were included from the Swedish catheter ablation registry and the Atrial Fibrillation Ablation Long-Term registry of the European Heart Rhythm Association of the European Society of Cardiology. The primary endpoint was repeat AF ablation. The major secondary endpoints included procedural duration, tachyarrhythmia recurrence, and complication rate. The re-ablation rate after 12 months was significantly lower in the CRYO vs. the RF group, 7.8% vs. 11%, P = 0.005, while freedom from arrhythmia recurrence (30 s duration) did not differ between the groups, 70.2 % vs. 68.2%, P = 0.44. The result was not influenced by AF type and lesion sets applied. In the Cox regression analysis, paroxysmal AF had significantly lower risk for re-ablation with CRYO, hazard ratio 0.56 (P = 0.041). Procedural duration was significantly shorter with CRYO than RF, (mean ± SD) 133.6 ± 45.2 min vs. 174.6 ± 58.2 min, P < 0.001. Complication rates were similar; 53/982 (5.4%) vs. 191/3675 (5.2%), CRYO vs. RF, P = 0.806.

    Conclusion: The lower re-ablation rates and shorter procedure times observed with the cryoballoon as compared to RF ablation may have important clinical implications when choosing AF ablation technique despite recognized limitations with registries.

  • 12.
    Mörtsell, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Jansson, Victoria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Lönnerholm, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Blomström-Lundqvist, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology.
    Clinical outcome of the 2nd generation cryoballoon for pulmonary vein isolation in patients with persistent atrial fibrillation – a sub-study of the randomized trial evaluating single versus dual cryoballoon applications2018In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754Article in journal (Refereed)
    Abstract [en]

    Aims

    To assess the efficacy of the 2nd generation Cryoballoon for pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (PersAF), and to compare it to patients with paroxysmal atrial fibrillation (PAF).

    Methods

    The outcome (arrhythmia recurrence at 12 months) was prospectively assessed in patients with PersAF(n=77) and compared to that in patients with PAF(n=62), who underwent PVI within a randomized trial evaluating single versus dual applications with the 2nd generation cryoballoon. Other endpoints included symptoms of AF, quality of life, procedure related characteristics, redo ablation rates and adverse events. Variables predicting recurrences were studied including all patients.

    Results

    Freedom from arrhythmia recurrence was 64.9% after a single ablation and 68.8% after one or more procedures, which was significantly lower compared to PAF patients; 82.2% (p=0.029) and 83.9% (p=0.048) respectively, at 12 months. The improvements in EHRA score (-1.3±0.8, p<0.0001), symptom severity score (SSQ) (-5.0±4.2, p<0.0001) and EQ5D-5L global score (+10.4±20.3, p=0.0002) after ablation was significant compared to baseline. The re-ablation rate was 7/77 (9.1%) which did not differ from that in PAF patients, 9/62 (14.5%), p=0.42. Procedure duration, 104.8±37.4 versus 113±31.2 minutes (p=0.129), application time, 1605±659 versus 1521±557 seconds (p=0.103) and total adverse events after 12 months, 8/77 (10.4%) versus 5/62 (8.1%) (p=0.77) did not differ in PersAF versus PAF patients.

    Conclusion

    Both symptoms and QoL improved significantly in patients with PersAF after ablation. Freedom from AF was clinically significant but lower than in PAF patients. The cryoballoon seems an effective technique also in patients with persistent AF.

  • 13.
    Mörtsell, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Jansson, Victoria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Lönnerholm, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Blomström-Lundqvist, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Clinical outcome of the 2nd generation cryoballoon for pulmonary vein isolation in patients with persistent atrial fibrillation — A sub-study of the randomized trial evaluating single versus dual cryoballoon applications2019In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 278, p. 120-125, article id S0167-5273(18)35500-1Article in journal (Refereed)
    Abstract [en]

    Aims: To assess the efficacy of the 2nd generation Cryoballoon for pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (PersAF), and to compare it to patients with paroxysmal atrial fibrillation (PAF).

    Methods: The outcome (arrhythmia recurrence at 12 months) was prospectively assessed in patients with PersAF(n = 77) and compared to that in patients with PAF(n = 62), who underwent PVI within a randomized trial evaluating single versus dual applications with the 2nd generation cryoballoon. Other endpoints included symptoms of AF, quality of life, procedure related characteristics, redo ablation rates and adverse events. Variables predicting recurrences were studied including all patients.

    Results: Freedom from arrhythmia recurrence was 64.9% after a single ablation and 68.8% after one or more procedures, which was significantly lower compared to PAF patients; 82.2% (p = 0.029) and 83.9% (p = 0.048) respectively, at 12 months. The improvements in EHRA score (−1.3 ± 0.8, p < 0.0001), symptom severity score (SSQ) (−5.0 ± 4.2, p < 0.0001) and EQ5D-5 L global score (+10.4 ± 20.3, p = 0.0002) after ablation was significant compared to baseline. The re-ablation rate was 7/77 (9.1%) which did not differ from that in PAF patients, 9/62 (14.5%), p = 0.42. Procedure duration, 104.8 ± 37.4 versus 113 ± 31.2 min (p = 0.129), application time, 1605 ± 659 versus 1521 ± 557 s (p = 0.103) and total adverse events after 12 months, 8/77 (10.4%) versus 5/62 (8.1%) (p = 0.77) did not differ in PersAF versus PAF patients.

    Conclusion: Both symptoms and QoL improved significantly in patients with PersAF after ablation. Freedom from AF was clinically significant but lower than in PAF patients. The cryoballoon seems an effective technique also in patients with persistent AF.

  • 14.
    Mörtsell, David
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Lönnerholm, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Jansson, Victoria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Blomström-Lundqvist, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Acute and long-term efficacy and safety with a single cryoballoon application as compared with the standard dual application strategy: a prospective randomized study using the second-generation cryoballoon for pulmonary vein isolation in patients with symptomatic atrial fibrillation2018In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 20, no 10, p. 1598-1605Article in journal (Refereed)
    Abstract [en]

    Aims

    A single cryoballoon (CB) application per vein for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) could save time and was therefore compared to the standard approach of two consecutive CB applications for acute and long-term efficacy and safety.

    Methods and results

    Patients with symptomatic AF were randomized to a single CB application per vein guided by an Achieve® catheter (Single cryo-arm) or to two CB applications using a standard guidewire (Routine cryo-arm). The primary endpoint was the rate of acute complete PVI. Secondary endpoints were freedom from AF evaluated by electrocardiogram and 7 days Holter at 6 and 12 months, symptoms by Symptom Severity Questionnaires and EHRA score and quality of life (QoL) by EQ5D-5L at 12 months. Among 140 patients included, PVI was achieved in 271 (100%) veins in the Single cryo-arm and in 269/271 (99.3%) veins in the Routine cryo-arm, P = 0.25. The procedure time was shorter in the Single cryo-arm, mean ± standard deviation 99.4 ± 33.3 min vs. 118.4 ± 34.3 min, P = 0.0015. Freedom from AF after one procedure at 12 months did not differ; 73.9.0% (Single cryo) vs. 71.4% (Routine), P = 0.74. Symptoms and QoL did also not differ between the two groups. There was a lower complication rate in the Single cryo-group, 2.9% vs. 12.9%, P = 0.03.

    Conclusion

    A single CB application shortens the procedure time without affecting acute or long-term efficacy, as compared to the routine two-application strategy, which with the lower complication rates has important implications when defining standards for PVI.

  • 15.
    Probst, Johan
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology.
    Jideus, Lena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Blomström, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Zemgulis, Vitas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Wassberg, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery. Uppsala Univ, Inst Surg Sci, Dept Cardiothorac Surg, Uppsala, Sweden..
    Lönnerholm, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Malmborg, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Blomström-Lundqvist, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.
    Thoracoscopic epicardial left atrial ablation in symptomatic patients with atrial fibrillation2016In: Europace, ISSN 1099-5129, E-ISSN 1532-2092, Vol. 18, no 10, p. 1538-1544Article in journal (Refereed)
    Abstract [en]

    The low efficacy rates reported for conventional catheter ablation of longstanding persistent atrial fibrillation (LPAF) have led to the development of alternative techniques such as minimal invasive surgical ablation, aiming for durable and contiguous transmural lesions. The aim was to evaluate the efficacy and safety of total thoracoscopic epicardial left atrial ablation (TELA-AF) procedures in a prospective study of severely symptomatic patients with either drug-resistant AF and/or failed attempts of catheter ablation. The TELA-AF surgical technique includes pulmonary vein isolation, left atrial (LA) 'box lesion', and partial vagal denervation. The LA appendage was excluded if deemed safe. Patients were followed with clinical evaluations and 12-lead electrocardiograms at 3, 6, and 12 months after the surgical intervention, complemented with a 7-day Holter monitoring after 6 and 12 months. Sixty patients, of whom 38 (63%) suffered from LPAF, underwent TELA-AF between November 2008 and December 2010. One patient with LPAF was lost to follow-up. At 12-month follow-up, 55/59 patients (93%) were free from atrial fibrillation (AF), while 7/59 patients (12%) suffered from recurrent LA tachycardia. Among patients with LPAF, 32/37 (86%) maintained sinus rhythm after 12 months. Adverse events included four perioperative bleedings requiring conversion to sternotomy in three cases, two ischaemic strokes and one transient ischaemic attack. The total thoracoscopic surgical ablation procedure is highly effective even in patients with LPAF, and it seems safe. The high rate of iatrogenic LA re-entrant tachycardia, however, warrants further improvement of the technique.

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