title: Balloon warming time is the strongest predictor of late pulmonary vein electrical reconnection following cryoballoon ablation for atrial fibrillation.
abstract: BACKGROUND
  Pulmonary vein isolation by cryoballoon ablation is an accepted method of treating atrial fibrillation. Little data exist regarding factors affecting late electrical reconnection of pulmonary veins following cryoballoon ablation.
  
  
  OBJECTIVE
  To investigate factors determining pulmonary vein reconnection in patients undergoing repeat catheter ablation for recurrent atrial fibrillation following cryoballoon ablation.
  
  
  METHODS
  Fifty-one consecutive patients undergoing repeat catheter ablation for recurrent atrial fibrillation following initial cryoballoon ablation underwent retrospective assessment of initial cryoablation characteristics, including balloon and vein sizes, venogram occlusion score, balloon freezing time from 0 to -30 °C, nadir temperature, and balloon warming time from -30 to +15 °C, recorded during the initial cryoballoon procedure.
  
  
  RESULTS
  Of 199 veins assessed, 91 had reconnected (1.8 per patient). Balloon warming time (odds ratio [OR] 3.21; 95% confidence interval [CI] 2.00-5.13; P < .0001), nadir temperature (OR 1.94; 95% CI 1.42-2.66; P < .0001), vein occlusion score (OR 1.74; 95% CI 1.29-2.34; P = .0003), and balloon freezing time (OR 1.58; 95% CI 1.03-2.42; P = .037) predicted pulmonary vein reconnection. On multivariate analysis, balloon warming time (OR 3.71; 95% CI 2.2-6.24; P ≤ .0001), pulmonary vein size (OR 1.63; 95% CI 1.08-2.43; P = .020), and vein occlusion score (OR 1.48; 95% CI 1.06-2.08; P = .021) remained statistically significant independent predictors of pulmonary vein reconnection. The receiver operating characteristic for the multivariate model yielded an area under the curve of 0.82.
  
  
  CONCLUSIONS
  Balloon warming time, vein occlusion score, and pulmonary vein size predict pulmonary vein reconnection. Balloon warming time was the most important predictive factor, and the manipulation of balloon warming may be a novel therapeutic strategy for improving outcomes of cryoballoon ablation for atrial fibrillation.
authors.affiliation: Royal Prince Alfred Hospital, Sydney, Australia.
authors.forename: Justin
authors.initials: J
authors.lastname: Ghosh
authors.forename: Andrew
authors.initials: A
authors.lastname: Martin
authors.forename: Anthony C
authors.initials: AC
authors.lastname: Keech
authors.forename: Kim H
authors.initials: KH
authors.lastname: Chan
authors.forename: Sean
authors.initials: S
authors.lastname: Gomes
authors.forename: Suresh
authors.initials: S
authors.lastname: Singarayar
authors.forename: Mark A
authors.initials: MA
authors.lastname: McGuire
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000601:surgery*; D021721:Balloon Occlusion / Q000379:methods*; D017115:Catheter Ablation; D003452:Cryosurgery; D004867:Equipment Design; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011667:Pulmonary Veins / Q000601:surgery; D012372:ROC Curve; D012008:Recurrence; D019233:Retreatment; D013696:Temperature
keywords: AF; AUC; Ablation; Atrial fibrillation; Balloon warming time; CI; Cryoballoon; IBD; LIPV; LSPV; OR; PV; PVI; RIPV; ROC; RSPV; Reconnection; Recurrence; area under the curve; atrial fibrillation; confidence interval; immediate balloon deflation; left inferior pulmonary vein; left superior pulmonary vein; odds ratio; pulmonary vein; pulmonary vein isolation; receiver operating characteristic; right inferior pulmonary vein; right superior pulmonary vein