Left Atrial Fibrosis after Single Shot Guided Pulmonary Vein Isolation

Cryoballoon (CB)-based pulmonary vein isolation (PVI) is an effective treatment modality for patients with atrial fibrillation (AF) with encouraging acute and long-term outcome data. However, the size of collaterally created lesion sets adjacent to the pulmonary veins (PVs) remains unclear, especially when CB ablation is performed with individualized time-to-isolation (TTI) protocols. This study seeks to investigate the extension of lesions at the posterior wall and the roof of the left atrium (LA). Thirty patients with paroxysmal or persistent AF underwent ablation with a fourth-generation CB. The individual freeze-cycle duration was set at TTI + 120 s. A total of 120 PVs were identified, and all were successfully isolated. A three-dimensional electroanatomical high-density (HD) mapping of the LA was performed in every patient before and after PVI. The surface areas of the posterior wall and LA roof were measured and compared with lesion extension after PVI. After CB ablation, 65.6 ± 16.9% of the posterior wall and 75.4 ± 18.4% of the LA roof remained unablated. In addition, non-antral lesion formation was observed in every patient in at least one PV. After CB ablation, anterior antral parts of the superior PVs showed the greatest unablated areas compared with the other antral areas. HD re-mapping after CB-based PVI demonstrated that major regions of the posterior wall and roof remained electrically normal and unaffected. Unablated antral areas were localized predominantly in the anterior segments of the superior PVs and may be partly responsible for AF recurrence.