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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">There is increasing interest in single-shot techniques for the electrical isolation of the pulmonary veins in patients with atrial fibrillation &#40;AF&#41;&#46; Ablation using the cryoballoon is the most widely performed single-shot technique for AF ablation&#44; although other techniques and equipment are also available&#46; To date&#44; equipment for cryoballoon ablation has been provided by one manufacturer only&#44; but in the near future cryoablation with new balloon-type catheters or using alternative sources of energy &#40;radiofrequency or lasers&#44; for example&#41; will be made available by other manufacturers&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Several factors have contributed to the increasing interest in single-shot techniques&#46; Firstly&#44; it is known that the incidence and prevalence of AF are significantly higher than initially thought&#44; particularly in its paroxysmal form&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> This is the likely result of the aging of the population and increasing prevalence of age-related conditions associated with AF&#44; such as hypertension&#44; diabetes and sleep apnea&#46; Secondly&#44; common sense dictates that the longer the monitoring period the higher the likelihood of finding AF&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> and therefore with better and more prolonged screening methods&#44; more patients can be expected to be diagnosed with the condition&#46; Thirdly&#44; although AF prevalence increases with age&#44; physicians are increasingly required to treat younger patients for whom chronic antiarrhythmic therapy is not an attractive option&#46; Except for beta-blockers and calcium channel blockers&#44; which have only modest efficacy for AF control&#44; the long-term safety of antiarrhythmic drugs is questionable at best&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Early diagnosis and treatment of patients with AF&#44; which includes risk factor modification&#44; catheter ablation and anticoagulation when indicated&#44; affects not only arrhythmia burden and quality of life&#44; but also associated morbidity and mortality&#46; This is particularly important for specific subgroups of patients such as those with heart failure and left ventricular systolic dysfunction&#44; who may derive prognostic benefit from AF ablation&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">3&#44;4</span></a> In a subanalysis of the Randomized Evaluation of Long-Term Anticoagulant Therapy &#40;RE-LY&#41; trial&#44; only around 7&#37; of deaths among anticoagulated AF patients were due to stroke or peripheral embolism&#44; with most deaths resulting from other cardiac causes or non-cardiovascular conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a> This highlights the efficacy of anticoagulation and adjuvant treatments in the prevention of stroke&#46; As patients on adequate anticoagulation are already at very low risk of cardioembolic stroke&#44; and given the lack of temporal relationship between episodes of AF and stroke&#44; future discussion should focus on the issue of mortality reduction as an important goal of AF treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> In the recently published CABANA trial&#44; intention-to-treat analysis showed no prognostic benefit of ablation compared with antiarrhythmic drugs&#44; although the as-treated and per-protocol analyses suggested a benefit for those who were actually treated&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> Importantly&#44; the subanalysis on patients with heart failure did show a strong trend for prognostic benefit of ablation&#44; even in the intention-to-treat analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> The question of whether AF ablation may also reduce the long-term risk of dementia is also worthy of further research&#46; In summary&#44; AF patients should be diagnosed and treated at an earlier stage of their condition&#44; preferably with a more efficacious treatment such as catheter ablation&#44; in order to reduce the morbidity and potentially the mortality associated with AF&#46; The reduction of stroke risk is undoubtedly an important goal but this may be achieved with anticoagulation if indicated by the patient&#39;s CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc score&#44; as well as with risk factor modification&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">To accomplish the objective of reducing the overall epidemiological burden of AF and associated morbidity&#44; it is paramount that the number of centers providing this treatment is increased&#44; and that each center performs an increasing number of ablations per year&#46; Cryoballoon ablation may be useful in this regard&#44; enabling an increase in the overall number of cases given the faster learning curve even in less experienced centers and the similar success rates compared with radiofrequency ablation&#44; a technique which is more dependent on operator experience&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Elvira Ruiz et al&#46; report medium- and long-term results of a single Medtronic second-generation cryoballoon &#40;CB2&#41;-based ablation procedure in patients with paroxysmal and persistent AF&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> All patients who underwent a first ablation procedure for AF using the CB2 technique in this single tertiary center between June 2012 and June 2017 were retrospectively analyzed&#46; A total of 172 patients &#40;134 with paroxysmal and 38 with persistent AF&#41; were included and acute success was achieved in the vast majority&#46; After a median follow-up of 27 months&#44; 58&#46;1&#37; of patients remained free of atrial arrhythmias &#40;64&#46;2&#37; and 36&#46;8&#37; for paroxysmal and persistent AF&#44; respectively&#41;&#46; Left atrial size and clinical presentation as persistent &#40;compared with paroxysmal&#41; AF were predictors of recurrence&#44; as expected&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This study&#44; carried out in a relatively small-volume center which performs 50-70 AF ablations per year&#44; including 35 with the cryoballoon&#44; nicely illustrates the notion that effective and safe cryoballoon AF ablation can be performed even in small centers&#46; In fact&#44; results and complication rates were in line with those seen in higher-volume hospitals&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> A previous study involving Portuguese hospitals and a higher number of patients showed very similar results&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> Still&#44; the faster learning curve of cryoballoon AF ablation should be weighed against the more precise point-by-point ablation achieved with radiofrequency contact-force catheters&#44; particularly in an era where the extent and transmurality of the ablation can be estimated with great precision with software such as Ablation Index &#40;Biosense Webster&#44; Inc&#41;&#46; The present study further confirmed what multiple investigators have already shown&#58; left atrial size and type of AF clearly impact the outcome&#46; The retrospective nature of this study is of course its main limitation&#44; and it is likely that some AF episodes may have been missed&#46; Nevertheless&#44; AF recurrence may not be as clinically relevant if episodes are of short duration&#44; and the patient is asymptomatic and on adequate anticoagulation if indicated&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; assuming the cryoballoon is non-inferior to other current techniques&#44; as previous studies have suggested&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">12&#44;13</span></a> AF ablation with this technology enables AF treatment to be widened with similar outcomes to the more traditional point-by-point radiofrequency ablation&#44; a welcome benefit in an era in which the demand for AF treatment is rapidly increasing&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Editorial comment
Standardizing atrial fibrillation ablation with the cryoballoon: A song of ice versus fire?
Normalizar a ablação da fibrilhação auricular com criobalão: o Gelo versus o Fogo?
João Primoa,b,
Corresponding author
joaojoseprimo@gmail.com

Corresponding author.
, Sérgio Barraa,b,c
a Cardiology Department, V. N. Gaia Hospital Center, Vila Nova de Gaia, Portugal
b Cardiology Department, Hospital da Luz Arrábida, Vila Nova de Gaia, Portugal
c Cardiology Department, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">There is increasing interest in single-shot techniques for the electrical isolation of the pulmonary veins in patients with atrial fibrillation &#40;AF&#41;&#46; Ablation using the cryoballoon is the most widely performed single-shot technique for AF ablation&#44; although other techniques and equipment are also available&#46; To date&#44; equipment for cryoballoon ablation has been provided by one manufacturer only&#44; but in the near future cryoablation with new balloon-type catheters or using alternative sources of energy &#40;radiofrequency or lasers&#44; for example&#41; will be made available by other manufacturers&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Several factors have contributed to the increasing interest in single-shot techniques&#46; Firstly&#44; it is known that the incidence and prevalence of AF are significantly higher than initially thought&#44; particularly in its paroxysmal form&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> This is the likely result of the aging of the population and increasing prevalence of age-related conditions associated with AF&#44; such as hypertension&#44; diabetes and sleep apnea&#46; Secondly&#44; common sense dictates that the longer the monitoring period the higher the likelihood of finding AF&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> and therefore with better and more prolonged screening methods&#44; more patients can be expected to be diagnosed with the condition&#46; Thirdly&#44; although AF prevalence increases with age&#44; physicians are increasingly required to treat younger patients for whom chronic antiarrhythmic therapy is not an attractive option&#46; Except for beta-blockers and calcium channel blockers&#44; which have only modest efficacy for AF control&#44; the long-term safety of antiarrhythmic drugs is questionable at best&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Early diagnosis and treatment of patients with AF&#44; which includes risk factor modification&#44; catheter ablation and anticoagulation when indicated&#44; affects not only arrhythmia burden and quality of life&#44; but also associated morbidity and mortality&#46; This is particularly important for specific subgroups of patients such as those with heart failure and left ventricular systolic dysfunction&#44; who may derive prognostic benefit from AF ablation&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">3&#44;4</span></a> In a subanalysis of the Randomized Evaluation of Long-Term Anticoagulant Therapy &#40;RE-LY&#41; trial&#44; only around 7&#37; of deaths among anticoagulated AF patients were due to stroke or peripheral embolism&#44; with most deaths resulting from other cardiac causes or non-cardiovascular conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a> This highlights the efficacy of anticoagulation and adjuvant treatments in the prevention of stroke&#46; As patients on adequate anticoagulation are already at very low risk of cardioembolic stroke&#44; and given the lack of temporal relationship between episodes of AF and stroke&#44; future discussion should focus on the issue of mortality reduction as an important goal of AF treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> In the recently published CABANA trial&#44; intention-to-treat analysis showed no prognostic benefit of ablation compared with antiarrhythmic drugs&#44; although the as-treated and per-protocol analyses suggested a benefit for those who were actually treated&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> Importantly&#44; the subanalysis on patients with heart failure did show a strong trend for prognostic benefit of ablation&#44; even in the intention-to-treat analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> The question of whether AF ablation may also reduce the long-term risk of dementia is also worthy of further research&#46; In summary&#44; AF patients should be diagnosed and treated at an earlier stage of their condition&#44; preferably with a more efficacious treatment such as catheter ablation&#44; in order to reduce the morbidity and potentially the mortality associated with AF&#46; The reduction of stroke risk is undoubtedly an important goal but this may be achieved with anticoagulation if indicated by the patient&#39;s CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc score&#44; as well as with risk factor modification&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">To accomplish the objective of reducing the overall epidemiological burden of AF and associated morbidity&#44; it is paramount that the number of centers providing this treatment is increased&#44; and that each center performs an increasing number of ablations per year&#46; Cryoballoon ablation may be useful in this regard&#44; enabling an increase in the overall number of cases given the faster learning curve even in less experienced centers and the similar success rates compared with radiofrequency ablation&#44; a technique which is more dependent on operator experience&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Elvira Ruiz et al&#46; report medium- and long-term results of a single Medtronic second-generation cryoballoon &#40;CB2&#41;-based ablation procedure in patients with paroxysmal and persistent AF&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> All patients who underwent a first ablation procedure for AF using the CB2 technique in this single tertiary center between June 2012 and June 2017 were retrospectively analyzed&#46; A total of 172 patients &#40;134 with paroxysmal and 38 with persistent AF&#41; were included and acute success was achieved in the vast majority&#46; After a median follow-up of 27 months&#44; 58&#46;1&#37; of patients remained free of atrial arrhythmias &#40;64&#46;2&#37; and 36&#46;8&#37; for paroxysmal and persistent AF&#44; respectively&#41;&#46; Left atrial size and clinical presentation as persistent &#40;compared with paroxysmal&#41; AF were predictors of recurrence&#44; as expected&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This study&#44; carried out in a relatively small-volume center which performs 50-70 AF ablations per year&#44; including 35 with the cryoballoon&#44; nicely illustrates the notion that effective and safe cryoballoon AF ablation can be performed even in small centers&#46; In fact&#44; results and complication rates were in line with those seen in higher-volume hospitals&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> A previous study involving Portuguese hospitals and a higher number of patients showed very similar results&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> Still&#44; the faster learning curve of cryoballoon AF ablation should be weighed against the more precise point-by-point ablation achieved with radiofrequency contact-force catheters&#44; particularly in an era where the extent and transmurality of the ablation can be estimated with great precision with software such as Ablation Index &#40;Biosense Webster&#44; Inc&#41;&#46; The present study further confirmed what multiple investigators have already shown&#58; left atrial size and type of AF clearly impact the outcome&#46; The retrospective nature of this study is of course its main limitation&#44; and it is likely that some AF episodes may have been missed&#46; Nevertheless&#44; AF recurrence may not be as clinically relevant if episodes are of short duration&#44; and the patient is asymptomatic and on adequate anticoagulation if indicated&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; assuming the cryoballoon is non-inferior to other current techniques&#44; as previous studies have suggested&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">12&#44;13</span></a> AF ablation with this technology enables AF treatment to be widened with similar outcomes to the more traditional point-by-point radiofrequency ablation&#44; a welcome benefit in an era in which the demand for AF treatment is rapidly increasing&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Revista Portuguesa de Cardiologia (English edition)
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