Differences in Post Ablation Cardiac MRI Scar Between Radiofrequency and
Cryoballoon Ablation: A DECAAF II Sub-analysis
Abstract
Introduction: Pulmonary vein isolation (PVI) using
radiofrequency (RF) and cryoballoon (Cryo) ablation are standard
approaches for rhythm control of symptomatic atrial fibrillation. Both
strategies involve scar formation of the left atrium (LA). There have
been few studies investigating the differences in residual fibrosis and
scar formation in patients undergoing RF and Cryo using cardiac magnetic
resonance imaging (CMR). Methods: The current study is a
sub-analysis of the control arm of the Delayed-Enhancement MRI
Determinant of Successful Catheter Ablation of Atrial Fibrillation study
(DECAAF II). The study was a multicenter, randomized, controlled, single
blinded trial that evaluated atrial arrhythmia recurrence (AAR) between
PVI alone and PVI plus CMR atrial fibrosis guided ablation. Pre-ablation
CMR and 3–6-month post ablation CMR were obtained to assess baseline LA
fibrosis and scar formation respectively. Results: Of the
843 patients randomized in the DECAAF II trial, we analyzed the 408
patients in the primary analysis control arm that received standard PVI.
Five patients received combined RF and Cryo ablations so were excluded
from this sub-analysis. Of the 403 patients analyzed, 345 underwent RF
and 58 Cryo. The average procedure duration was 146 minutes for RF and
103 minutes for Cryo (p = 0.001). The rate of AAR at ~15
months occurred in 151 (43.8%) patients in the RF group and 28 (48.3%)
patients in the Cryo group (p = 0.62). On 3-month post CMR the RF arm
had significantly more covered fibrosis (3.6% vs. 3.0%, p = 0.04) and
scar (8.8% vs. 6.4%, p = 0.001) compared to Cryo. Patients with ≥
6.5% LA scar on 3-month post CMR had less AAR independent of ablation
technique (RF p = 0.009, Cryo p = 0.02). Cryo caused a greater
percentage of right and left pulmonary vein (PV) scar (p = 0.04, p =
0.02) and less non-PV scar (p = 0.009) compared to RF. On Cox regression
Cryo patients free of AAR had a greater percentage of left PV scar (p =
0.01) and less non-PV scar (p = 0.004) compared to RF free of AAR.
Conclusion: In this sub-analysis of the control arm of the
DECAAF II trial, there was no significant difference in the rate of AAR
in patients undergoing PVI alone between RF vs. Cryo. Post ablation LA
scar ≥ 6.5% predicted freedom from AAR, independent of ablation
technique. Cryo formed a greater percentage of PV scar and less non-PV
scar compared to RF, which may have prognostic implications.