Comparison of left ventricular cryolesions created by liquid nitrogen and nitrous oxide

The surgical treatment of atrial fibrillation

Atrial fibrillation is a complex disease affecting a significant portion of the general population. Although medical therapy is the mainstay of treatment, intervention plays an important role in selected patients. The Cox-Maze procedure is the gold standard for the surgical treatment of atrial fibrillation and has more than 90% success in eliminating atrial fibrillation. Ablation technologies have played a key role in simplifying this technically demanding procedure and making it available to more patients. A myriad of new lesion sets and approaches were introduced over the last decade which has made the operative treatment of atrial fibrillation less invasive and more confusing.

Experimental cryosurgery investigations in vivo

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.

Endocardial hypothermia and pulmonary vein isolation with epicardial cryoablation in a porcine beating-heart model

OBJECTIVE

The objective of this study was to investigate whether epicardial cryoablation could achieve sufficient endocardial hypothermia to create transmural lesions leading to acute and sustained pulmonary vein isolation in a normothermic beating-heart model.

METHODS

Thirty-five- to 45-kg pigs underwent median sternotomy. Epicardial cryoablation was performed on the right ventricle after insertion of thermocouples. Endocardial temperatures from thermocouples were recorded continuously and correlated with the thickness of the myocardium. Thirteen animals underwent pulmonary vein isolation as a box lesion by using 5-minute epicardial cryoablation. Endocardial temperatures were measured in 5 of these animals. Ten animals survived for 7 or 30 days. Electrical isolation was tested at the time of surgical intervention and again at death. Hearts were removed en bloc and submitted for gross and microscopic examination.

RESULTS

Endocardial temperature varied inversely with tissue thickness, ranging from -60 degrees C in 5-mm-thick tissue to staying unchanged in tissue more than 10 mm thick. During pulmonary vein isolation, median endocardial temperatures were between -1 degrees C and -22 degrees C. Acute electrical isolation was achieved in all 13 animals. All except one of the animals maintained electrical isolation long-term. Histologic analysis revealed transmurality in 89% of sections, although none of the box lesions were completely transmural.

CONCLUSION

Epicardial cryoablation can produce long-term pulmonary vein isolation in a beating heart. Dose-response studies demonstrate consistent endocardial hypothermia in tissues up to 7 mm thick. To our knowledge, this is the first report documenting endocardial hypothermia during epicardial cryoablation. This technology holds promise for performing the complete maze procedure on a beating heart.

Cryothermal ablation: mechanism of tissue injury and current experience in the treatment of tachyarrhythmias

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.