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Journal of Cardiovascular... Sep 2021In May 2020, a novel cryoballoon system (POLARx; Boston Scientific) became available for catheter ablation of atrial fibrillation (AF). The design of the cryoballoon is... (Meta-Analysis)
Meta-Analysis
Comparison of procedural efficacy, balloon nadir temperature, and incidence of phrenic nerve palsy between two cryoballoon technologies for pulmonary vein isolation: A systematic review and meta-analysis.
INTRODUCTION
In May 2020, a novel cryoballoon system (POLARx; Boston Scientific) became available for catheter ablation of atrial fibrillation (AF). The design of the cryoballoon is comparable to the Arctic Front Advance Pro (AFA-Pro; Medtronic), but it is more compliant during freezing. We compared the procedural efficacy, biophysical parameters, and risk of phrenic nerve palsy (PNP) between the two cryoballoons.
METHODS
Embase, MEDLINE, Web of Science, Cochrane, and Google Scholar databases were searched until June 1, 2021 for relevant studies comparing POLARx versus AFA-Pro in patients undergoing pulmonary vein isolation (PVI) for AF.
RESULTS
A total of four studies, involving 310 patients were included. There was no difference between the two groups for outcomes regarding procedural efficacy: acute PVI (odds ratio [OR]: 0.43; 95% confidence interval [CI]: 0.06 to 3.03; p = .40), procedure time (mean difference [MD]: 8.15 min; 95% CI: -8.09 to 24.39; p = .33), fluoroscopy time (MD: 1.32 min; 95% CI: -1.61 to 4.25; p = .38) and ablation time (MD: 1.00 min; 95% CI: -0.20 to 2.20; p = .10). The balloon nadir temperature was lower for all individual pulmonary veins (PV) in POLARx compared with AFA-Pro (MD: -9.74°C, -9.98°C, -6.72°C, -7.76°C, for left superior PV, left inferior PV, right superior PV, and right inferior PV, respectively; all p < .001). The incidence of PNP was similar between groups (OR: 0.79; 95% CI: 0.22 to 2.85; p = .72).
CONCLUSION
In AF patients undergoing PVI, POLARx and AFA-Pro had a similar procedural efficacy. Balloon nadir temperatures were lower with POLARx, however, the incidence of PNP was similar.
Topics: Atrial Fibrillation; Catheter Ablation; Cryosurgery; Humans; Incidence; Paralysis; Phrenic Nerve; Pulmonary Veins; Temperature; Treatment Outcome
PubMed: 34289198
DOI: 10.1111/jce.15182 -
Frontiers in Cardiovascular Medicine 2021Catheter ablation has become a well-established indication for long-term rhythm control in atrial fibrillation (AF) patients refractory to anti-arrhythmic drugs (AADs)....
Catheter Ablation vs. Anti-Arrhythmic Drugs as First-Line Treatment in Symptomatic Paroxysmal Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.
Catheter ablation has become a well-established indication for long-term rhythm control in atrial fibrillation (AF) patients refractory to anti-arrhythmic drugs (AADs). Efficacy and safety of AF catheter ablation (AFCA) before AADs failure are, instead, questioned. The aim of the study was to perform a systematic review and meta-analysis of randomized clinical trials (RCTs) comparing first-line AFCA with AADs in symptomatic patients with paroxysmal AF. We performed a random-effects meta-analysis of binary outcome events comparing AFCA with AADs in rhythm control-naïve patients. The primary outcomes, also stratified by the type of ablation energy (radiofrequency or cryoenergy), were (1) recurrence of atrial tachyarrhythmias and (2) recurrence of symptomatic atrial tachyarrhythmias. The secondary outcomes included adverse events. Six RCTs were included in the analysis. AFCA was associated with lower recurrences of atrial tachyarrhythmias [relative risk (RR) 0.58, 95% confidence interval (CI) 0.46-0.72], consistent across the two types of ablation energy (radiofrequency, RR 0.50, 95% CI 0.28-0.89; cryoenergy, RR 0.60, 95% CI 0.50-0.72; -value for subgroup differences: 0.55). Similarly, AFCA was related to less symptomatic arrhythmic recurrences (RR 0.46, 95% CI 0.27-0.79). Overall, adverse events did not differ. A trend toward increased periprocedural cardiac tamponade or phrenic nerve palsy was observed in the AFCA group, while more atrial flutter episodes with 1:1 atrioventricular conduction and syncopal events were reported in the AAD group. First-line rhythm control therapy with AFCA, independent from the adopted energy source (radiofrequency or cryoenergy), reduces long-term arrhythmic recurrences in patients with symptomatic paroxysmal AF compared with AADs.
PubMed: 34095254
DOI: 10.3389/fcvm.2021.664647 -
Journal of Atrial Fibrillation 2020The Right phrenic nerve (RPN) is vulnerable to injury during the isolation of the right pulmonary veins (RPV). The study aimed to provide a comprehensive meta-analysis...
BACKGROUND
The Right phrenic nerve (RPN) is vulnerable to injury during the isolation of the right pulmonary veins (RPV). The study aimed to provide a comprehensive meta-analysis of the overall prevalence of right phrenic nerve injury (RPNI), its course and its association with the superior and inferior pulmonary veins.
METHODS
Through December 2017, a database search was performed on PubMed, Science Direct, EMBASE, SciELO, and Web of Science. The references were also extensively searched in the included articles.
RESULTS
Detection of the RPN may vary according to the identification method. It ranges from 100% in postmortem studies, 93% in intraoperative, to 57.88% in computer tomography (CT) imaging. Based on the included studies (n-507), the distance from the right superior pulmonary vein (RSPV) ostium to the RPN was 12.48mm (±6.21). In postmortem studies, the distance was 6.92mm (±3.94); in pre or intraoperative techniques, 13.32mm (±5.96) if noninvasive, 13.97mm (±7.8) if invasive. Distances ranged from 0DC342.6 mm. For the right inferior pulmonary vein (RIPV) (n-125) the mean distance was 16.53mm (±8.92) with distances from 0.4 68mm. The risk of RPNI with distance-included studies was 12.46% (47 RPNI in 377 cases). In the meta-analysis, the distance from the RSPV to the RPN that was associated with an increased risk of RPNI was 7.36mm.
CONCLUSIONS
RPNI is a relatively rare complication. A firm understanding of its course, relation to the PV ostium, and detection are vital for preventing future injuries and complications.
PubMed: 34950302
DOI: 10.4022/jafib.2305 -
Diagnostics (Basel, Switzerland) Nov 2019The diagnosis of neck pain is challenging. Many visceral disorders are known to cause it, and clinical practice guidelines recommend to rule them out during neck pain... (Review)
Review
The diagnosis of neck pain is challenging. Many visceral disorders are known to cause it, and clinical practice guidelines recommend to rule them out during neck pain diagnosis. However, the absence of suspicion of any cause impedes one from establishing that specific aetiology as the final diagnosis. To investigate the degree of consideration given to visceral aetiology, a systematic search of trials about neck pain was carried out to evaluate their selection criteria. The search yielded 309 eligible articles, which were screened by two independent reviewers. The PEDro scale score was used to assess the methodological quality of the studies. The following information was retrieved: number of authors affiliated to a clinical or non-clinical institution, number of citations in the Web of Science, study aims, characteristics of participants, and eligibility criteria. The top 15 most cited trials, and the 15 most recent studies about treatment efficacy in neck pain, published in first quartile journals of the Journal Citation Reports, were selected. Females represented 67.5% of participants. A single study was of poor methodological quality (4/10). Based on the eligibility criteria of the articles that were systematically reviewed, it would appear that visceral aetiology was not considered in eighty percent of the trials on neck pain, showing a low level of suspicion both in research and clinical settings.
PubMed: 31726685
DOI: 10.3390/diagnostics9040186 -
Kardiologia Polska Jan 2020Clinical outcomes of catheter ablation for persistent atrial fibrillation (AF) remain discouraging. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Clinical outcomes of catheter ablation for persistent atrial fibrillation (AF) remain discouraging.
AIM
This meta‑analysis aimed to compare cryoballoon ablation (CBA) with radiofrequency ablation (RFA) for persistent AF.
METHODS
A systematic search of the PubMed, EMBASE, and Cochrane Library databases was performed for studies comparing the outcomes between CBA and RFA. Seven trials including 934 patients were analyzed.
RESULTS
There were no differences between groups in terms of freedom from atrial arrhythmia (risk ratio [RR], 1.04; 95% CI, 0.93-1.15; P = 0.52; I2 = 0%), procedural complications (RR, 0.91; 95% CI, 0.52-1.59; P = 0.74; I2 = 0%), atrial fibrillation or atrial tachycardia relapse during the blanking period (RR, 0.73; 95% CI, 0.50-1.06; P = 0.1; I2 = 9%), repeat ablation (RR, 0.74; 95% CI, 0.45-1.21; P = 0.23; I2 = 62%), and vascular complications (RR, 0.98; 95% CI, 0.42-2.27; P = 0.97; I2 = 0%). Cryoballoon ablation increased the incidence of conversion to sinus rhythm during ablation (RR, 1.69; 95% CI, 1.01-2.83; P = 0.046; I2 = 0%) and phrenic nerve palsy (PNP; RR, 3.05; 95% CI, 0.95-9.8; P = 0.06; I2 = 0%), while RFA increased the risk of cardiac tamponade (RR, 0.27; 95% CI, 0.06-1.25; P = 0.09; I2 = 0%). Subanalyses revealed a lower incidence of recurrent atrial arrhythmia and repeat ablation during CBA without touch‑up RFA in pulmonary vein isolation.
CONCLUSIONS
CBA provides an alternative technique for persistent AF ablation. It might reduce the risk of repeat ablation and cardiac tamponade but increase the risk of PNP.
Topics: Atrial Fibrillation; Catheter Ablation; Cryosurgery; Humans; Pulmonary Veins; Recurrence; Treatment Outcome
PubMed: 31688837
DOI: 10.33963/KP.15048 -
Current Cardiology Reviews 2019Ablation therapy is the treatment of choice in antiarrhythmic drugrefractory atrial fibrillation (AF). It is performed by either cryoballoon ablation (CBA) or... (Meta-Analysis)
Meta-Analysis
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.
Topics: Atrial Fibrillation; Catheter Ablation; Cryosurgery; Female; Humans; Male; Middle Aged; Treatment Outcome
PubMed: 30539701
DOI: 10.2174/1573403X15666181212102419 -
PloS One 2018Growing evidence suggests that second-generation cryoballoon ablation (2G-CB) is effective in patients with persistent atrial fibrillation (PerAF). The cornerstone of... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Growing evidence suggests that second-generation cryoballoon ablation (2G-CB) is effective in patients with persistent atrial fibrillation (PerAF). The cornerstone of atrial fibrillation (AF) ablation is pulmonary vein isolation (PVI). The purpose of this study was to summarize the available data on the safety and mid-term (≥ 12 months) effectiveness of a 'PVI-only' strategy vs. a 'PVI-plus' strategy using 2G-CB in patients with PerAF.
METHODS
We searched the PubMed, EMBASE and Cochrane library databases for studies on 2G-CB for PerAF. Group analysis was based on the ablation approach: 'PVI-only' versus 'PVI-plus', the latter of which involved PVI plus other substrate modifications. Studies showing clinical success rates at a follow-up (FU) of ≥ 12 months were included. Complication rates were also assessed. Data were analyzed by applying a fixed effects model.
RESULTS
A total of 879 patients from 5 studies were analyzed. After a mid-term FU of 27 months, the overall success rate of 2G-CB for PerAF was 66.1%. In the 'PVI-plus' group, the success rate was 73.8%. In the 'PVI-only' group, the success rate was 53.6%. No heterogeneity was noted among studies (I2 = 0.0%, P = 0.82). Complications occurred in 5.2% of patients (P = 0.93), and the rate of phrenic nerve (PN) injury was 2.8% (P = 0.14). Vascular assess complications were the most frequent at 1.6% (P = 0.33). No death or myocardial infarction was reported.
CONCLUSION
'PVI-plus' involving 2G-CB seems to be safe and effective for treating PerAF.
Topics: Aged; Atrial Fibrillation; Cardiac Surgical Procedures; Catheter Ablation; Cryosurgery; Female; Humans; Male; Middle Aged; Postoperative Complications; Pulmonary Veins; Recurrence; Risk Factors; Treatment Outcome
PubMed: 30359452
DOI: 10.1371/journal.pone.0206362 -
JACC. Clinical Electrophysiology Mar 2017The goal of this study was to describe short- and long-term outcomes in all patients referred for inappropriate sinus tachycardia ablation, along with the potential...
OBJECTIVES
The goal of this study was to describe short- and long-term outcomes in all patients referred for inappropriate sinus tachycardia ablation, along with the potential complications of the intervention.
BACKGROUND
Sinus node (SN) ablation/modification has been proposed for patients refractory to pharmacological therapy. However, available data derive from limited series.
METHODS
The electronic databases MEDLINE, Embase, CINAHL, Cochrane, and Scopus were systematically searched (January 1, 1995-December 31, 2015). Studies were screened according to predefined inclusion and exclusion criteria.
RESULTS
A total of 153 patients were included. Their mean age was 35.18 ± 10.02 years, and 139 (90.8%) were female. All patients had failed to respond to maximum tolerated doses of pharmacological therapy (3.5 ± 2.4 drugs). Mean baseline heart rates averaged 101.3 ± 16.4 beats/min according to electrocardiography and 104.5 ± 13.5 beats/min according to 24-h Holter monitoring. Two electrophysiological strategies were used, SN ablation and SN modification, with the latter being used more. Procedural acute success (using variably defined pre-determined endpoints) was 88.9%. Consistently, all groups reported high-output pacing from the ablation catheter to confirm absence of phrenic nerve stimulation before radiofrequency delivery. Need of pericardial access varied between 0% and 76.9%. Thirteen patients (8.5%) experienced severe procedural complications, and 15 patients (9.8%) required implantation of a pacemaker. At a mean follow-up interval of 28.1 ± 12.6 months, 86.4% of patients demonstrated successful outcomes. The symptomatic recurrence rate was 19.6%, and 29.8% of patients continued to receive antiarrhythmic drug therapy after procedural intervention.
CONCLUSIONS
Inappropriate sinus tachycardia ablation/modification achieves acute success in the vast majority of patients. Complications are fairly common and diverse. However, symptomatic relief decreases substantially over longer follow-up periods, with a corresponding high recurrence rate.
Topics: Adult; Anti-Arrhythmia Agents; Body Surface Potential Mapping; Catheter Ablation; Electrocardiography; Electrocardiography, Ambulatory; Electrophysiologic Techniques, Cardiac; Female; Follow-Up Studies; Humans; Male; Middle Aged; Pacemaker, Artificial; Pericardium; Phrenic Nerve; Recurrence; Sinoatrial Node; Tachycardia, Sinus; Treatment Outcome
PubMed: 29759520
DOI: 10.1016/j.jacep.2016.09.014 -
Respiratory Medicine Mar 2013Inspiratory muscle fatigue (IMF) may contribute to the development of exercise limitation and respiratory failure. Identifying fatigue of the inspiratory muscles... (Review)
Review
Inspiratory muscle fatigue (IMF) may contribute to the development of exercise limitation and respiratory failure. Identifying fatigue of the inspiratory muscles requires a rigorous and integrative methodological approach. However, there is no consensus about an optimal protocol to induce and assess the fatigability of the inspiratory muscles. A systematic review was performed to identify, evaluate, and summarize the literature related to the assessment of induced IMF in healthy individuals. The aim was to identify factors that are related consistently to IMF, as well as to suggest possible assessment methods. MEDLINE and EMBASE were searched for relevant articles until February 2012. Only studies with a quantitative description of assessment and outcome were included. The search yielded 460 citations and a total of 77 studies were included. Inspiratory muscle fatigue was produced acutely by inspiratory resistive loading (IRL), whole body exercise (WBE), hyperpnea, or WBE combined with IRL, and under normocapnic, hypoxic or hypercapnic conditions. To detect IMF, most studies (64%) used phrenic nerve stimulation, 44% used a maximal voluntary inspiratory maneuver and the remainder used electromyography. The heterogeneity of the published reports precluded a quantitative analysis. Inspiratory resistive loadings at intensities of 60-80% of maximum, and cycling at 85% of maximum were found to produce IMF most consistently. Hypoxic or hypercapnic conditions, and WBE combined with IRL, exacerbated IMF. The specific outcome measures employed to detect IMF, the magnitude of their change, as well as their functional significance, are ultimately dependent upon the research question being addressed.
Topics: Diaphragm; Electric Stimulation; Exercise Test; Humans; Muscle Fatigue; Phrenic Nerve; Respiratory Muscles
PubMed: 23273596
DOI: 10.1016/j.rmed.2012.11.019 -
Journal of Vascular Surgery Nov 2009Thoracic endografts (stent grafts) have emerged as a less invasive modality to treat various thoracic aortic lesions. The intentional coverage of the left subclavian... (Meta-Analysis)
Meta-Analysis Review
The effect of left subclavian artery coverage on morbidity and mortality in patients undergoing endovascular thoracic aortic interventions: a systematic review and meta-analysis.
OBJECTIVES
Thoracic endografts (stent grafts) have emerged as a less invasive modality to treat various thoracic aortic lesions. The intentional coverage of the left subclavian artery (LSA) during the placement of these endografts is associated with several complications including stroke, spinal cord ischemia, and arm ischemia. In this review, we synthesize the available evidence regarding the complications associated with LSA coverage.
METHODS
We searched electronic databases (MEDLINE and EMBASE) from January 1990 through February 2008 for studies that included patients who received thoracic endografts and had intentional LSA coverage. Eligible studies had a control group that either received the endograft without LSA coverage or had primary revascularization prior to coverage. Two independent reviewers determined trial eligibility and extracted descriptive, methodological and outcome data from each eligible study. Meta-analyses estimated Peto odds ratio (OR) and 95% confidence intervals (CI) to describe the strength of association between coverage and complications; the I(2) statistic described the proportion of inconsistency of treatment effect among studies not due to chance.
RESULTS
We found 51 eligible observational studies. LSA coverage was associated with significant increase in the risk of arm ischemia (OR 47.7; CI, 9.9-229.3; I(2) = 72%, 19 studies) and vertebrobasilar ischemia (OR 10.8; CI, 3.17-36.7; I(2) = 0%; eight studies); and nonsignificant increase in the risk of spinal cord ischemia (OR 2.69; CI, 0.75-9.68; I(2) = 40%; eight studies) and anterior circulation stroke (OR 2.58; CI, 0.82-8.09; I(2) = 64%, 13 studies). There were no significant associations between LSA coverage and death, myocardial infarction, or transient ischemic attacks. The incidence of phrenic nerve injury as a complication of primary revascularization was 4.40% (CI, 1.60%-12.20%). Data on perioperative infection were sparse and rarely reported.
CONCLUSIONS
Very low quality evidence suggests that LSA coverage increases the risk of arm ischemia, vertebrobasilar ischemia, and possibly spinal cord ischemia and anterior circulation stroke.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Aorta, Thoracic; Aortic Diseases; Arm; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Evidence-Based Medicine; Female; Humans; Ischemia; Male; Middle Aged; Odds Ratio; Patient Selection; Practice Guidelines as Topic; Prosthesis Design; Risk Assessment; Spinal Cord Ischemia; Stents; Stroke; Subclavian Artery; Treatment Outcome; Vertebrobasilar Insufficiency; Young Adult
PubMed: 19878792
DOI: 10.1016/j.jvs.2009.09.002