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Deshmukh A, Romano MA, Oral H. Hybrid ventricular tachycardia ablation: Choosing the right tool for the job. Heart Rhythm 2023; 20:1718-1719. [PMID: 37774775 DOI: 10.1016/j.hrthm.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023]
Affiliation(s)
- Amrish Deshmukh
- Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, Michigan
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hakan Oral
- Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, Michigan.
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Cox JL, Malaisrie SC, Churyla A, Mehta C, Kruse J, Kislitsina ON, McCarthy PM. Cryosurgery for Atrial Fibrillation: Physiologic Basis for Creating Optimal Cryolesions. Ann Thorac Surg 2021; 112:354-362. [PMID: 33279545 DOI: 10.1016/j.athoracsur.2020.08.114] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although cryosurgery has been used to treat cardiac arrhythmias for nearly 5 decades, the mechanism of action and the surgical technique that produces optimal cryolesions for the treatment of atrial fibrillation are still poorly understood. This has resulted in surgical outcomes that can be improved by a better understanding the mechanisms of cryothermia ablation and the proper surgical techniques that take advantage of those mechanisms. METHODS The cryobiology underlying cryosurgical ablation is described, as are the nuances of cryosurgical techniques that ensure the reliable creation of contiguous, uniformly transmural atrial cryolesions. The oft-misunderstood "2-minute rule" for the application of cryothermia is clarified in detail, along with its variations that depend on target myocardial temperature. RESULTS The creation of optimal cryolesions depends on cryoprobe temperature, the temperature of the target myocardium, the duration of cryothermia application, and the presence or absence of a "heat sink" or "cooling sink" created by intracavitary blood circulation. Cryothermia kills myocardial cells during both the freezing and thawing phases of cryoablation cycle. The critical lethal temperature for myocardium is -30°C. The slower the target tissue thaws, the higher the percentage of cell death. CONCLUSIONS The availability of cryosurgical techniques has revolutionized the surgical treatment of atrial fibrillation. By utilizing modern cryosurgical devices and adhering to the technical principles described, surgeons can now perform surgical procedures for atrial fibrillation that are quicker, safer, and as effective as the standard Maze-III/IV procedure.
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Affiliation(s)
- James L Cox
- Division of Cardiac Surgery, Feinberg School of Medicine and the Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois.
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Feinberg School of Medicine and the Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois
| | - Andrei Churyla
- Division of Cardiac Surgery, Feinberg School of Medicine and the Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois
| | - Chris Mehta
- Division of Cardiac Surgery, Feinberg School of Medicine and the Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois
| | - Jane Kruse
- Division of Cardiac Surgery, Feinberg School of Medicine and the Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois
| | - Olga N Kislitsina
- Division of Cardiac Surgery, Feinberg School of Medicine and the Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois; Division of Cardiology, Feinberg School of Medicine and the Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois
| | - Patrick M McCarthy
- Division of Cardiac Surgery, Feinberg School of Medicine and the Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois
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3
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Qian PC, Barry MA, Tran VT, Lu J, McEwan A, Thiagalingam A, Thomas SP. Irrigated Microwave Catheter Ablation Can Create Deep Ventricular Lesions Through Epicardial Fat With Relative Sparing of Adjacent Coronary Arteries. Circ Arrhythm Electrophysiol 2020; 13:e008251. [PMID: 32299229 DOI: 10.1161/circep.119.008251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Radiofrequency ablation depth can be inadequate to reach intramural or epicardial substrate, and energy delivery in the pericardium is limited by penetration through epicardial fat and coronary anatomy. We hypothesized that open irrigated microwave catheter ablation can create deep myocardial lesions endocardially and epicardially though fat while acutely sparing nearby the coronary arteries. METHODS In-house designed and constructed irrigated microwave catheters were tested in in vitro phantom models and in 15 sheep. Endocardial ablations were performed at 140 to 180 W for 4 minutes; epicardial ablations via subxiphoid access were performed at 90 to 100 W for 4 minutes at sites near coronary arteries. RESULTS Epicardial ablations at 90 to 100 W produced mean lesion depth of 10±4 mm, width 18±10 mm, and length 29±8 mm through median epicardial fat thickness of 1.2 mm. Endocardial ablations at 180 W reached depths of 10.7±3.3 mm, width of 16.6±5 mm, and length of 20±5 mm. Acute coronary occlusion or spasm was not observed at a median separation distance of 2.7 mm (IQR, 1.2-3.4 mm). Saline electrodes recorded unipolar and bipolar electrograms; microwave ablation caused reductions in voltage and changes in electrogram morphology with loss of pace-capture. In vitro models demonstrated the heat sink effect of coronary flow, as well as preferential microwave coupling to myocardium and blood as opposed to lung and epicardial fat phantoms. CONCLUSIONS Irrigated microwave catheter ablation may be an effective ablation modality for deep ventricular lesion creation with capacity for fat penetration and sparing of nearby coronary arteries because of cooling endoluminal flow. Clinical translation could improve the treatment of ventricular tachycardia arising from mid myocardial or epicardial substrates.
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Affiliation(s)
- Pierre C Qian
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia.,Sydney Medical School (P.C.Q., A.T., S.P.T.), University of Sydney, Australia.,The Westmead Institute for Medical Research (P.C.Q., A.T., S.P.T.), University of Sydney, Australia
| | - Michael A Barry
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia.,School of Electrical and Information Engineering (M.A.B., A.M.), University of Sydney, Australia
| | - Vu T Tran
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia
| | - Juntang Lu
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia
| | - Alistair McEwan
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia.,School of Electrical and Information Engineering (M.A.B., A.M.), University of Sydney, Australia
| | - Aravinda Thiagalingam
- Sydney Medical School (P.C.Q., A.T., S.P.T.), University of Sydney, Australia.,The Westmead Institute for Medical Research (P.C.Q., A.T., S.P.T.), University of Sydney, Australia
| | - Stuart P Thomas
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia.,Sydney Medical School (P.C.Q., A.T., S.P.T.), University of Sydney, Australia.,The Westmead Institute for Medical Research (P.C.Q., A.T., S.P.T.), University of Sydney, Australia
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4
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Surgical cryoablation for ventricular tachyarrhythmia arising from the left ventricular outflow tract region. Heart Rhythm 2015; 12:1128-36. [DOI: 10.1016/j.hrthm.2015.02.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Indexed: 11/24/2022]
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5
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Gage AA, Baust JM, Baust JG. Experimental cryosurgery investigations in vivo. Cryobiology 2009; 59:229-43. [PMID: 19833119 DOI: 10.1016/j.cryobiol.2009.10.001] [Citation(s) in RCA: 174] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 09/30/2009] [Accepted: 10/01/2009] [Indexed: 12/16/2022]
Abstract
Cryosurgery is the use of freezing temperatures to elicit an ablative response in a targeted tissue. This review provides a global overview of experimentation in vivo which has been the basis of advancement of this widely applied therapeutic option. The cellular and tissue-related events that underlie the mechanisms of destruction, including direct cell injury (cryolysis), vascular stasis, apoptosis and necrosis, are described and are related to the optimal methods of technique of freezing to achieve efficacious therapy. In vivo experiments with major organs, including wound healing, the putative immunological response following thawing, and the use of cryoadjunctive strategies to enhance cancer cell sensitivity to freezing, are described.
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Affiliation(s)
- A A Gage
- Department of Surgery, SUNY Buffalo, Buffalo, NY, USA
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Hashimoto K, Watanabe I, Okumura Y, Ohkubo K, Ashino S, Kofune M, Nakai T, Kunimoto S, Kasamaki Y, Hirayama A. Comparison of Endocardial and Epicardial Lesion Size Following Large-Tip and Extra-Large-Tip Transcatheter Cryoablation. Circ J 2009; 73:1619-26. [DOI: 10.1253/circj.cj-08-1211] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kenichi Hashimoto
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Ichiro Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Sonoko Ashino
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Masayoshi Kofune
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Satoshi Kunimoto
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Yuji Kasamaki
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
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KHAIRY PAUL, DUBUC MARC. Transcatheter Cryoablation Part I: Preclinical Experience. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 31:112-20. [DOI: 10.1111/j.1540-8159.2007.00934.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Nakamura Y, Nakano K, Nakatani H, Gomi A, Sato A, Sughimoto K. Easy Pulmonary Vein Isolation Using Epicardial Cryoablation. Surg Today 2006; 36:198-200. [PMID: 16440173 DOI: 10.1007/s00595-005-3133-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2005] [Accepted: 05/24/2005] [Indexed: 10/25/2022]
Abstract
The maze procedure can be accomplished by several techniques with varying degrees of success. These techniques include cut-and-sew, endocardial cryoablation, and epicardial ablation using heat-producing devices. We describe our surgical modification of pulmonary vein isolation with cryoablation using an epicardial and endocardial approach. This simple and reliable technique, which does not need any special device, will assist in mitral valve surgery for patients with chronic atrial fibrillation.
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Affiliation(s)
- Yoshitsugu Nakamura
- Department of Cardiovascular Surgery, Kanto Medical Center, NTT EC, 5-9-22 Higashigotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
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9
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Grassl ED, Bischof JC. In vitro model systems for evaluation of smooth muscle cell response to cryoplasty. Cryobiology 2005; 50:162-73. [PMID: 15843006 DOI: 10.1016/j.cryobiol.2005.01.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2004] [Revised: 10/18/2004] [Accepted: 01/06/2005] [Indexed: 11/17/2022]
Abstract
Restenosis is a major health care problem, with approximately 40% of angioplasties resulting in restenosis. Mechanisms related to elastic recoil, cell proliferation, and extracellular matrix (ECM) synthesis are implicated. In vivo studies have demonstrated the potential for cryotherapy to combat the process of restenosis, but the mechanisms whereby freezing and/or cooling can reduce or eliminate smooth muscle cell (SMC) proliferation and ECM synthesis are not well known. While in vivo testing is ultimately necessary, in vitro models can provide important information on thermal parameters and mechanisms of injury. However, it is important to carefully choose the model system for in vitro work on cryoinjury characterization to adequately reflect the clinical situation. In this study, we examined the differences in response to cryoinjury by SMCs from different species (rat, pig, and human) and in different cellular environments (suspension vs. tissue equivalent). Tissue equivalents, composed of cells embedded in collagen or fibrin gel, provide a 3-D tissue-like environment, while allowing for controlled composition. As reported here, all SMCs showed similar trends, but rat cells appeared less sensitive to cooling at faster cooling rates in suspension, while human SMCs were less sensitive to temperatures just above freezing when embedded in collagen. In addition, the SMCs were less sensitive in suspension than they were in collagen. Cells in suspension exhibited 70% viability at -11 degrees C, whereas cells in the tissue equivalent model showed only 30% survival. Future studies will aim to more adequately represent the conditions in restenosis by providing inflammatory and proliferative cues to the cells.
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Affiliation(s)
- Erin D Grassl
- Department of Mechanical Engineering, University of Minnesota, Minneapolis, MN 55455, USA
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Lustgarten DL, Bell S, Hardin N, Calame J, Spector PS. Safety and efficacy of epicardial cryoablation in a canine model. Heart Rhythm 2005; 2:82-90. [PMID: 15851270 DOI: 10.1016/j.hrthm.2004.09.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2004] [Accepted: 09/17/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the safety and efficacy of cryoablation in a closed chest canine epicardial ablation model. BACKGROUND Limitations of radiofrequency energy in the epicardial space warrants investigation of alternative energy sources. METHODS A linear-tip catheter with a 3-cm freezing element and a 6-mm-tip catheter were used to create epicardial atrial and ventricular cryolesions. Epicardial coronary arteries were targeted to evaluate the effects of cryoablation on epicardial vessels. Cryoablation was performed at -90 degrees C for 4 minutes per lesion. Pathologic examination of the hearts was performed. Lesions were stained with tetrazolium chloride, analyzed grossly, and examined histologically. RESULTS Ten of 11 linear catheter atrial lesions were transmural (average depth 1.5 +/- 1.3 mm). Only three of 13 6-mm-tip atrial lesions were transmural (average depth 1.1 +/- 1.2 mm). Ventricular lesions were continuous and not transmural (average depth of lesion for the linear and 6-mm-tip catheters: 2.7 +/- 1.3 mm and 1.6 +/- 0.7 mm, respectively). Angiographic stenosis (20-100%) during freezing was detected in 9 of 28 lesions, with TIMI III flow present in all vessels 5 minutes following thaw. Neointimal proliferation was present in 13 vessels, with no evidence of damage in vessels with internal diameters greater than 0.7 mm. Occlusive injury was identified in one small branch vessel. CONCLUSIONS Creation of transmural lesions was possible in the atria but not in the ventricles. Cryothermal ablation can cause neointimal proliferation, with the probability that damage will be directly proportional to lesion depth and inversely proportional to vessel diameter.
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12
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Lee JW, Choo SJ, Kim KI, Song JK, Kang DH, Song JM, Song H, Lee SK, Song MG. Atrial fibrillation surgery simplified with cryoablation to improve left atrial function. Ann Thorac Surg 2001; 72:1479-83. [PMID: 11722029 DOI: 10.1016/s0003-4975(01)03176-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The Maze procedure restores atrial fibrillation to normal sinus rhythm. However, concurrent left atrial functional recovery is not always achieved. To address this limitation, a modification using linear cryoablation is described. METHODS Between July 1997 and December 1999, 83 patients received atrial fibrillation surgery in association with mitral valve surgery with or without additional concurrent procedures by either the conventional technique, group I (n = 30) or the modified technique, group II (n = 53). Onset of sinus conversion and echocardiographic assessment of postoperative left ventricular function, left atrial size, and mitral A-wave velocity were compared in the early postoperative period and 6 months after surgery. RESULTS Sinus conversion occurred significantly earlier in group II, 2.4 +/- 5 days versus group I, 7.0 +/- 10 days. The mean transmitral A-wave velocity and the incidence of A-wave appearance in the early postoperative period and 6 months postoperatively were greater in group II than group I. CONCLUSIONS With the current modification, restoration of sinus rhythm and superior left atrial contractile function occurred earlier than with the standard Maze III technique.
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Affiliation(s)
- J W Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea.
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Berreklouw E, Bracke F, Meijer A, Peels KH, Relik D. Cardiogenic shock due to coronary narrowings one day after a MAZE III procedure. Ann Thorac Surg 1999; 68:1065-6. [PMID: 10510011 DOI: 10.1016/s0003-4975(99)00744-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A MAZE III procedure was performed on a patient with a small body surface area. On the first postoperative day, the patient developed severe dysfunction of the left ventricle, due to significant narrowings of the right and circumflex coronary arteries in the areas that were cryoablated during the MAZE III procedure. The coronary narrowings were treated by percutaneous transluminal coronary angioplasty (PTCA). At discharge the coronary anatomy was normal again with an almost normal left ventricular function.
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Affiliation(s)
- E Berreklouw
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands.
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Lustgarten DL, Keane D, Ruskin J. Cryothermal ablation: mechanism of tissue injury and current experience in the treatment of tachyarrhythmias. Prog Cardiovasc Dis 1999; 41:481-98. [PMID: 10445872 DOI: 10.1016/s0033-0620(99)70024-1] [Citation(s) in RCA: 186] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cryosurgery has been an integral part of the surgical management of cardiac arrhythmias since the late 1970s. With the recent development of intravenous cryocatheters, the use of cryothermy in the treatment of cardiac arrhythmias will increase in the near future. The following discussion includes a detailed consideration of the mode of tissue injury associated with cryothermy and a comprehensive review of cryosurgery in the management of a variety of cardiac arrhythmias. Cryosurgical management of supraventricular and ventricular tachycardias has proven to be both safe and effective. Cryothermal tissue injury is distinguished from hyperthermic injury by the preservation of basic underlying tissue architecture and minimal thrombus formation. Such differences will be particularly important in settings requiring extensive lesion formation, such as catheter-based maze procedures for the treatment of atrial fibrillation.
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Affiliation(s)
- D L Lustgarten
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston 02114, USA
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Bakker PF, Elbers HR, Vermeulen FE, Robles de Medina EO. Effects of cryothermia during cold cardioplegia on epicardial and intramural coronary arteries. Ann Thorac Surg 1993; 55:127-30. [PMID: 8417659 DOI: 10.1016/0003-4975(93)90487-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Cryosurgery is playing an increasingly important role in the surgical treatment of various supraventricular and ventricular tachyarrhythmias. The short-term and long-term effects of cryogenic injury on epicardial and intramural coronary arteries were studied in 22 dogs. Transmural cryolesions encompassing a posterolateral branch of the circumflex coronary artery were produced in the inferior left ventricular wall during extracorporeal circulation and cold cardioplegic arrest. The mean epicardial cryolesion area +/- standard deviation was 10.4 +/- 1.8 cm2. The mean epicardial coronary artery diameter +/- standard deviation measured 1.2 +/- 0.4 mm. At 6 hours, no important structural changes were noted in any of 6 dogs. At 48 hours, 1 of 2 epicardial coronary arteries showed recent thrombus. At 1, 3, and 6 months, the epicardial coronary arteries were occluded due to thrombosis and intimal hyperplasia in 13 of 14 dogs. A limited degree of recanalization was observed. At all follow-up intervals, the intramural coronary arteries exhibited a histologic pattern similar to that of the epicardial coronary arteries. It is concluded that the exposure of major epicardial coronary arteries to cryoinjury during cold cardioplegic arrest should be avoided where possible.
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Affiliation(s)
- P F Bakker
- Heart Lung Institute, University Hospital Utrecht, The Netherlands
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