PMC:6019327 / 141064-143806 JSONTXT

{"project":"2_test","denotations":[{"id":"28506916-23500312-45814710","span":{"begin":563,"end":566},"obj":"23500312"},{"id":"28506916-23500312-45814710","span":{"begin":563,"end":566},"obj":"23500312"},{"id":"28506916-21457789-45814711","span":{"begin":567,"end":570},"obj":"21457789"},{"id":"28506916-21457789-45814711","span":{"begin":567,"end":570},"obj":"21457789"},{"id":"28506916-20129295-29307865","span":{"begin":737,"end":740},"obj":"20129295"},{"id":"28506916-20129295-29307865","span":{"begin":737,"end":740},"obj":"20129295"},{"id":"28506916-23398599-29307866","span":{"begin":1147,"end":1150},"obj":"23398599"},{"id":"28506916-23398599-29307866","span":{"begin":1147,"end":1150},"obj":"23398599"},{"id":"28506916-24678900-29307867","span":{"begin":1151,"end":1154},"obj":"24678900"},{"id":"28506916-24678900-29307867","span":{"begin":1151,"end":1154},"obj":"24678900"},{"id":"28506916-24610797-29307868","span":{"begin":1155,"end":1158},"obj":"24610797"},{"id":"28506916-24610797-29307868","span":{"begin":1155,"end":1158},"obj":"24610797"},{"id":"28506916-25618741-29307869","span":{"begin":1159,"end":1162},"obj":"25618741"},{"id":"28506916-25618741-29307869","span":{"begin":1159,"end":1162},"obj":"25618741"},{"id":"28506916-27085722-29307870","span":{"begin":1163,"end":1166},"obj":"27085722"},{"id":"28506916-27085722-29307870","span":{"begin":1163,"end":1166},"obj":"27085722"},{"id":"28506916-27042964-29307871","span":{"begin":1167,"end":1170},"obj":"27042964"},{"id":"28506916-27042964-29307871","span":{"begin":1167,"end":1170},"obj":"27042964"},{"id":"28506916-27381589-29307872","span":{"begin":1171,"end":1174},"obj":"27381589"},{"id":"28506916-27381589-29307872","span":{"begin":1171,"end":1174},"obj":"27381589"},{"id":"28506916-27390961-29307873","span":{"begin":1175,"end":1178},"obj":"27390961"},{"id":"28506916-27390961-29307873","span":{"begin":1175,"end":1178},"obj":"27390961"},{"id":"28506916-26504108-29307874","span":{"begin":1179,"end":1182},"obj":"26504108"},{"id":"28506916-26504108-29307874","span":{"begin":1179,"end":1182},"obj":"26504108"},{"id":"28506916-26698157-29307875","span":{"begin":1183,"end":1186},"obj":"26698157"},{"id":"28506916-26698157-29307875","span":{"begin":1183,"end":1186},"obj":"26698157"},{"id":"28506916-27042964-29307876","span":{"begin":1426,"end":1429},"obj":"27042964"},{"id":"28506916-27042964-29307876","span":{"begin":1426,"end":1429},"obj":"27042964"},{"id":"28506916-26163901-29307877","span":{"begin":1584,"end":1587},"obj":"26163901"},{"id":"28506916-26163901-29307877","span":{"begin":1584,"end":1587},"obj":"26163901"},{"id":"28506916-27381589-29307878","span":{"begin":1755,"end":1758},"obj":"27381589"},{"id":"28506916-27381589-29307878","span":{"begin":1755,"end":1758},"obj":"27381589"},{"id":"28506916-25618741-29307879","span":{"begin":1878,"end":1881},"obj":"25618741"},{"id":"28506916-25618741-29307879","span":{"begin":1878,"end":1881},"obj":"25618741"},{"id":"28506916-27390961-29307880","span":{"begin":1882,"end":1885},"obj":"27390961"},{"id":"28506916-27390961-29307880","span":{"begin":1882,"end":1885},"obj":"27390961"},{"id":"28506916-25972302-45814712","span":{"begin":2137,"end":2140},"obj":"25972302"},{"id":"28506916-25972302-45814712","span":{"begin":2137,"end":2140},"obj":"25972302"},{"id":"28506916-25972302-29307882","span":{"begin":2446,"end":2449},"obj":"25972302"},{"id":"28506916-25972302-29307882","span":{"begin":2446,"end":2449},"obj":"25972302"},{"id":"T93115","span":{"begin":563,"end":566},"obj":"23500312"},{"id":"T94452","span":{"begin":563,"end":566},"obj":"23500312"},{"id":"T4863","span":{"begin":567,"end":570},"obj":"21457789"},{"id":"T861","span":{"begin":567,"end":570},"obj":"21457789"},{"id":"T61605","span":{"begin":737,"end":740},"obj":"20129295"},{"id":"T61341","span":{"begin":737,"end":740},"obj":"20129295"},{"id":"T84394","span":{"begin":1147,"end":1150},"obj":"23398599"},{"id":"T90793","span":{"begin":1147,"end":1150},"obj":"23398599"},{"id":"T76762","span":{"begin":1151,"end":1154},"obj":"24678900"},{"id":"T59050","span":{"begin":1151,"end":1154},"obj":"24678900"},{"id":"T93882","span":{"begin":1155,"end":1158},"obj":"24610797"},{"id":"T45444","span":{"begin":1155,"end":1158},"obj":"24610797"},{"id":"T33050","span":{"begin":1159,"end":1162},"obj":"25618741"},{"id":"T84813","span":{"begin":1159,"end":1162},"obj":"25618741"},{"id":"T4158","span":{"begin":1163,"end":1166},"obj":"27085722"},{"id":"T98853","span":{"begin":1163,"end":1166},"obj":"27085722"},{"id":"T37348","span":{"begin":1167,"end":1170},"obj":"27042964"},{"id":"T62704","span":{"begin":1167,"end":1170},"obj":"27042964"},{"id":"T11114","span":{"begin":1171,"end":1174},"obj":"27381589"},{"id":"T213","span":{"begin":1171,"end":1174},"obj":"27381589"},{"id":"T73972","span":{"begin":1175,"end":1178},"obj":"27390961"},{"id":"T41233","span":{"begin":1175,"end":1178},"obj":"27390961"},{"id":"T91603","span":{"begin":1179,"end":1182},"obj":"26504108"},{"id":"T20309","span":{"begin":1179,"end":1182},"obj":"26504108"},{"id":"T3043","span":{"begin":1183,"end":1186},"obj":"26698157"},{"id":"T54042","span":{"begin":1183,"end":1186},"obj":"26698157"},{"id":"T87848","span":{"begin":1426,"end":1429},"obj":"27042964"},{"id":"T44878","span":{"begin":1426,"end":1429},"obj":"27042964"},{"id":"T28467","span":{"begin":1584,"end":1587},"obj":"26163901"},{"id":"T27885","span":{"begin":1584,"end":1587},"obj":"26163901"},{"id":"T8797","span":{"begin":1755,"end":1758},"obj":"27381589"},{"id":"T31812","span":{"begin":1755,"end":1758},"obj":"27381589"},{"id":"T57091","span":{"begin":1878,"end":1881},"obj":"25618741"},{"id":"T85214","span":{"begin":1878,"end":1881},"obj":"25618741"},{"id":"T40664","span":{"begin":1882,"end":1885},"obj":"27390961"},{"id":"T7751","span":{"begin":1882,"end":1885},"obj":"27390961"},{"id":"T66709","span":{"begin":2137,"end":2140},"obj":"25972302"},{"id":"T99892","span":{"begin":2137,"end":2140},"obj":"25972302"},{"id":"T9508","span":{"begin":2446,"end":2449},"obj":"25972302"},{"id":"T68423","span":{"begin":2446,"end":2449},"obj":"25972302"},{"id":"T91892","span":{"begin":563,"end":566},"obj":"23500312"},{"id":"T66808","span":{"begin":563,"end":566},"obj":"23500312"},{"id":"T5324","span":{"begin":567,"end":570},"obj":"21457789"},{"id":"T79227","span":{"begin":567,"end":570},"obj":"21457789"},{"id":"T96799","span":{"begin":737,"end":740},"obj":"20129295"},{"id":"T34555","span":{"begin":737,"end":740},"obj":"20129295"},{"id":"T39347","span":{"begin":1147,"end":1150},"obj":"23398599"},{"id":"T1594","span":{"begin":1147,"end":1150},"obj":"23398599"},{"id":"T78515","span":{"begin":1151,"end":1154},"obj":"24678900"},{"id":"T46822","span":{"begin":1151,"end":1154},"obj":"24678900"},{"id":"T73030","span":{"begin":1155,"end":1158},"obj":"24610797"},{"id":"T39297","span":{"begin":1155,"end":1158},"obj":"24610797"},{"id":"T74794","span":{"begin":1159,"end":1162},"obj":"25618741"},{"id":"T80356","span":{"begin":1159,"end":1162},"obj":"25618741"},{"id":"T60162","span":{"begin":1163,"end":1166},"obj":"27085722"},{"id":"T66804","span":{"begin":1163,"end":1166},"obj":"27085722"},{"id":"T18895","span":{"begin":1167,"end":1170},"obj":"27042964"},{"id":"T96043","span":{"begin":1167,"end":1170},"obj":"27042964"},{"id":"T27429","span":{"begin":1171,"end":1174},"obj":"27381589"},{"id":"T58907","span":{"begin":1171,"end":1174},"obj":"27381589"},{"id":"T42092","span":{"begin":1175,"end":1178},"obj":"27390961"},{"id":"T35231","span":{"begin":1175,"end":1178},"obj":"27390961"},{"id":"T57727","span":{"begin":1179,"end":1182},"obj":"26504108"},{"id":"T28242","span":{"begin":1179,"end":1182},"obj":"26504108"},{"id":"T19955","span":{"begin":1183,"end":1186},"obj":"26698157"},{"id":"T51819","span":{"begin":1183,"end":1186},"obj":"26698157"},{"id":"T7476","span":{"begin":1426,"end":1429},"obj":"27042964"},{"id":"T53976","span":{"begin":1426,"end":1429},"obj":"27042964"},{"id":"T1183","span":{"begin":1584,"end":1587},"obj":"26163901"},{"id":"T70330","span":{"begin":1584,"end":1587},"obj":"26163901"},{"id":"T79345","span":{"begin":1755,"end":1758},"obj":"27381589"},{"id":"T1127","span":{"begin":1755,"end":1758},"obj":"27381589"},{"id":"T99278","span":{"begin":1878,"end":1881},"obj":"25618741"},{"id":"T47839","span":{"begin":1878,"end":1881},"obj":"25618741"},{"id":"T84023","span":{"begin":1882,"end":1885},"obj":"27390961"},{"id":"T33893","span":{"begin":1882,"end":1885},"obj":"27390961"},{"id":"T63696","span":{"begin":2137,"end":2140},"obj":"25972302"},{"id":"T21940","span":{"begin":2137,"end":2140},"obj":"25972302"},{"id":"T58785","span":{"begin":2446,"end":2449},"obj":"25972302"},{"id":"T92783","span":{"begin":2446,"end":2449},"obj":"25972302"}],"text":"Obtaining Permanent PVI with the Cryoballoon\nThe first-generation CB was introduced approximately 10 years ago and consisted of a noncompliant balloon with two different diameters (23 mm and 28 mm), using N2O as the refrigerant. A stiff wire or a spiral mapping catheter (Achieve, Medtronic, Inc.) is inserted via a central lumen of the catheter shaft. Applying the first-generation CB and freeze cycle durations of 300 seconds, successful PVI was routinely followed by a bonus freeze cycle of the same duration. The 1-year success rate was approximately 70%–73%.462,482 More than 80% of the patients with AF recurrence after first-generation CB-based PVI demonstrated recurrence of conduction at the time of a repeat ablation procedure.483 The second-generation CB (Arctic Front Advance, Medtronic, Inc.) was introduced in 2012 and incorporates a modified refrigerant injection system characterized by 8 injection jets in a more distal balloon position. Thus, a more homogeneous cooling of the complete distal balloon hemisphere, including the distal tip, was achieved. Multiple studies have demonstrated clinical success rates of 65% or greater.484,485,486,487,488,489,490,491,492,493 The recently published FIRE AND ICE trial was the first to compare the acute and long-term efficacy as well as the safety profile of the second-generation CB with conventional RFC ablation in a prospective, randomized, multicenter fashion.489 The study demonstrated the noninferiority of CBA compared with RF-based ablation with respect to efficacy and safety of patients with drug-refractory PAF.494 However, secondary endpoints, such as the rate of rehospitalization and reablations, or the necessity of electrical cardioversion during follow-up were in favor of CB.490 Among patients who fail AF ablation with the CB2 system, recurrent PV conduction is observed in 27% to 65% of patients.487,491 The role of adenosine in revealing dormant conduction has also been evaluated. One study reported that administration of 12 mg or more of adenosine (titrated to AV block) 30 minutes postablation resulted in an 11% incidence of recurrent PV conduction.495 A second study reported similar findings, with a 12% incidence of recurrent conduction after a waiting phase plus adenosine administration. This small study of 90 patients reported a higher success rate (84% vs 79%) when a strategy of reablation based on adenosine-induced dormant conduction was targeted.495\nA survey of the writing group shows that only 51% of the writing group members employ a 20-minute or longer waiting phase when using CBA. This survey also revealed that 46% of operators routinely pace in the PV and employ exit block as a secondary endpoint during AF ablation using CB energy."}