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Zhang J, Li S, Sang C, Ma C. Atrial fibrillation catheter ablation associated silent cerebral emboli: A narrative review. Pacing Clin Electrophysiol 2023; 46:1124-1133. [PMID: 37578003 DOI: 10.1111/pace.14779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 08/15/2023]
Abstract
The incidence of silent cerebral emboli (SCE) associated with atrial fibrillation catheter ablation (AFCA) is much higher than that of stroke/transient ischemic attack (TIA). Interventional electrophysiologists have been increasingly alerted to asymptomatic cerebral infarction over the years. Plentiful studies revealed that diagnostic definitions, detection modalities, energy sources, ablation strategies, perioperative anticoagulation regimens, and patient-related factors were associated with the risk of AFCA-associated SCE. Studies related to non-interventional procedures found that SCE may prompt stroke, cognitive decline, and dementia later in life, suggesting a possible role of AFCA-associated SCE in the cognitive function of patients with AF. However, there is no consistent evidence for this view to date. Given that the majority of patients with AF being elderly and the increased risk of cognitive impairment in AF itself, efforts should be made to minimize the occurrence of AFCA-associated SCE.
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Affiliation(s)
- Jingrui Zhang
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Songnan Li
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Caihua Sang
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Changsheng Ma
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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Yokoyama M, Tokuda M, Tokutake K, Sato H, Oseto H, Yokoyama K, Kato M, Narui R, Tanigawa SI, Yamashita S, Yoshimura M, Yamane T. Effect of air removal with extracorporeal balloon inflation on incidence of asymptomatic cerebral embolism during cryoballoon ablation of atrial fibrillation: A prospective randomized study. IJC HEART & VASCULATURE 2022; 40:101020. [PMID: 35434257 PMCID: PMC9010628 DOI: 10.1016/j.ijcha.2022.101020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 11/04/2022]
Abstract
Background It was previously reported, based on a retrospective study, that preliminary removal of air bubbles in heparinized saline water with extracorporeal balloon inflation reduced the incidence of asymptomatic cerebral embolism (ACE). The present study aims to compare the incidence of ACE between a conventional and pre-inflation method during cryoballoon ablation in a prospective randomized controlled study. Methods A total of 98 atrial fibrillation patients were enrolled and randomized into conventional and pre-inflation groups. Patients in the pre-inflation group received balloon massaging with preliminary extracorporeal balloon inflation in saline water before the cryoballoon was inserted into the body. Results The baseline characteristics were similar between the two groups. Post-procedural 3-Tesla MRI revealed CE in 27.6% of patients. Symptomatic CE only occurred in two patients in the pre-inflation group. One patient had transient dysarthria and mild muscle weakness in one hand; the other patient complained of transient left upper limb weakness, left lower limb paresthesia and dysarthria. The incidence of ACE detected by cerebral MRI did not differ between the two groups to a statistically significant extent (conventional vs. pre-inflation; 22.9% vs. 29.2%; P = 0.49). In the multivariable analysis, eGFR was independently associated with the presence of ACE (odds ratio 0.95; 95% confidence interval 0.907–0.995; P = 0.03). Conclusion In this prospective randomized study, the preliminary removal of air bubbles in heparinized saline water with extracorporeal balloon inflation had no impact on the incidence of ACE.
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto S, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 2021; 37:709-870. [PMID: 34386109 PMCID: PMC8339126 DOI: 10.1002/joa3.12491] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto SI, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2021; 85:1104-1244. [PMID: 34078838 DOI: 10.1253/circj.cj-20-0637] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, Kure Medical Center and Chugoku Cancer Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kaoru Okishige
- Department of Cardiology, Yokohama City Minato Red Cross Hospital
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Yoshihiro Seo
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Yuji Nakazato
- Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital
| | - Takashi Nishimura
- Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | - Yuji Murakawa
- Fourth Department of Internal Medicine, Teikyo University Hospital Mizonokuchi
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Inoue
- Division of Arrhythmia, Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Yuki Iwasaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kikuya Uno
- Arrhythmia Center, Chiba Nishi General Hospital
| | - Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | | | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | | | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University
| | - Tsugutoshi Suzuki
- Departments of Pediatric Electrophysiology, Osaka City General Hospital
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Masahiko Takagi
- Division of Cardiac Arrhythmia, Department of Internal Medicine II, Kansai Medical University
| | - Masaomi Chinushi
- School of Health Sciences, Faculty of Medicine, Niigata University
| | - Nobuhiro Nishi
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Hachiya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | | | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School Chiba-Hokusoh Hospital
| | - Aya Miyazaki
- Department of Pediatric Cardiology, Congenital Heart Disease Center, Tenri Hospital
| | - Tomoshige Morimoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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Long-term course of phrenic nerve injury after cryoballoon ablation of atrial fibrillation. Sci Rep 2021; 11:6226. [PMID: 33737633 PMCID: PMC7973708 DOI: 10.1038/s41598-021-85618-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/26/2021] [Indexed: 12/14/2022] Open
Abstract
While phrenic nerve palsy (PNP) due to cryoballoon pulmonary vein isolation (PVI) of atrial fibrillation (AF) was transient in most cases, no studies have reported the results of the long-term follow-up of PNP. This study aimed to summarize details and the results of long-term follow-up of PNP after cryoballoon ablation. A total of 511 consecutive AF patients who underwent cryoballoon ablation was included. During right-side PVI, the diaphragmatic compound motor action potential (CMAP) was reduced in 46 (9.0%) patients and PNP occurred in 29 (5.7%) patients (during right-superior PVI in 20 patients and right-inferior PVI in 9 patients). PNP occurred despite the absence of CMAP reduction in 0.6%. The PV anatomy, freezing parameters and the operator’s proficiency were not predictors of PNP. While PNP during RSPVI persisted more than 4 years in 3 (0.6%) patients, all PNP occurred during RIPVI recovered until one year after the ablation. However, there was no significant difference in the recovery duration from PNP between PNP during RSPVI and RIPVI. PNP occurred during cryoballoon ablation in 5.7%. While most patients recovered from PNP within one year after the ablation, PNP during RSPVI persisted more than 4 years in 0.6% of patients.
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Rottner L, Reissmann B, Schleberger R, Sinning C, Metzner A, Rillig A. [Management of acute complications during electrophysiological procedures]. Herzschrittmacherther Elektrophysiol 2020; 31:381-387. [PMID: 32676836 DOI: 10.1007/s00399-020-00698-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 06/21/2020] [Indexed: 06/11/2023]
Abstract
Catheter ablation is an established treatment option in patients suffering from symptomatic cardiac arrhythmias. However, despite technical advances, catheter ablation is still associated with an incidence of severe complications of up to 5%. Therefore, electrophysiologists should be trained to prevent complications, maintain a high index of suspicion to recognize them quickly and implement necessary treatment strategies. This article reviews the incidence, risk factors, management and preventative strategies of the major complications associated with ablation procedures such as transseptal puncture-related risks, cardiac tamponade, aortic puncture and air embolism.
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Affiliation(s)
- Laura Rottner
- Abteilung für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
| | - Bruno Reissmann
- Abteilung für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
| | - Ruben Schleberger
- Abteilung für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
| | - Christoph Sinning
- Abteilung für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
| | - Andreas Metzner
- Abteilung für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
| | - Andreas Rillig
- Abteilung für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland.
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Nakamura K, Sasaki T, Take Y, Minami K, Sasaki W, Kishi S, Yoshimura S, Okazaki Y, Miki Y, Goto K, Kaseno K, Yamashita E, Koyama K, Funabashi N, Naito S. Effect of preventing air intrusion on silent strokes during atrial fibrillation ablation using a mini-basket catheter. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 44:71-81. [PMID: 33216388 DOI: 10.1111/pace.14131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/04/2020] [Accepted: 11/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Air bubble intrusion through transseptal sheaths during left atrial (LA) catheter ablation can cause cerebral embolisms, especially when using complex-shape catheters. This study aimed to compare the incidence of silent cerebral events (SCEs) after atrial fibrillation (AF) catheter ablation using a mini-basket catheter (IntellaMap Orion; Boston Scientific) between the following groups: group SP, strict prevention of LA air intrusion and group CP, conventional air intrusion prevention. METHODS We enrolled 123 consecutive AF patients (group SP, n = 61 and group CP, n = 62) who underwent brain magnetic resonance imaging after a local-impedance-guided ablation using one mini-basket catheter and one circular mapping catheter. The preventive strategy in group SP included (a) the insertion of the mini-basket catheter into the transseptal sheaths in a container filled with heparinized saline and (b) no exchange of all catheters over the sheaths. RESULTS SCEs were detected in 67 patients (54.5%), and the incidence of SCEs did not significantly differ between groups SP and CP (55.7% vs 53.2%; P = .780). A multivariate analysis demonstrated that an older age, non-paroxysmal AF, and radiofrequency (RF) power output were independent positive predictors of SCEs (odds ratios: 1.079, 5.613, and 1.405; P = .005, <.001, and .012). On the follow-up MR imaging, 83.5% of the SCEs in group SP and 87.7% in group CP disappeared (P = .398). CONCLUSIONS Strict prevention of LA air intrusion may have no additional effect for reducing the incidence of SCEs after local impedance-guided AF ablation using a mini-basket catheter. An older age, non-paroxysmal AF, and high-power RF applications may increase the risk of SCEs.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Wataru Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Shohei Kishi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Shingo Yoshimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yoshinori Okazaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Koji Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Kenichi Kaseno
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
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Apte NM, Shrestha A, Dendi R. Techniques to Avoid Complications of Atrial Fibrillation Ablation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00834-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Okishige K, Hirao T, Oda A, Shigeta T, Nakamura RA, Yoshida H, Tachibana S, Yamauchi Y, Sasano T, Hirao K. Blood Coagulation Status during Cryofreezing Ablation and Effects of the Direct Anticoagulants Dabigatran and Edoxaban. Int Heart J 2020; 61:249-253. [PMID: 32173706 DOI: 10.1536/ihj.19-450] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cryoballoon ablation is an established catheter-based approach to treat atrial fibrillation (AF). However, thromboembolic events cannot be avoided during cryoablation. There is little data regarding the blood coagulation status during freezing.The thrombin antithrombin complex (TAT) and prothrombin fragment 1+2 (F 1+2) of patient blood were measured during cryoballoon application when the cryoballoon temperature reached the nadir in 63 AF patients. TAT was also measured from porcine blood during cryoballoon freezing in 5 pigs.The TAT and F 1+2 increased from 6.60 ± 5.65 to 9.16 ± 7.28 ng/mL (P = 0.004) and from 279.6 ± 146.4 to 323.6 ± 169.1 pmol/L (P = 0.003) between the control and during freezing, respectively. The TAT increased from 0.46 to 0.87 ng/mL during freezing compared to that of pre-freezing (P < 0.05), and it returned to 0.39 ng/mL in 30 minutes after an intravenous edoxaban administration (N.S.).Dabigatran failed to exert sufficient anticoagulant effects during cryofreezing. In contrast, intravenous edoxaban seemed to provoke anticoagulation effects under extreme low temperature circumstances.
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Affiliation(s)
- Kaoru Okishige
- Heart Center, Japan Red Cross Yokohama City Bay Hospital
| | | | - Atsushi Oda
- Heart Center, Japan Red Cross Yokohama City Bay Hospital
| | | | | | | | | | | | - Tetsuo Sasano
- Arrhythmia Center, Tokyo Medical and Dental University
| | - Kenzo Hirao
- Arrhythmia Center, Tokyo Medical and Dental University
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Reiss J, O'Connell H, Getman MK. Achieving contrast-free ultra-low radiation exposure without compromising safety and acute efficacy through evolving AF cryoballoon ablation procedure techniques. Int J Cardiol 2020; 299:153-159. [PMID: 31235200 DOI: 10.1016/j.ijcard.2019.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/10/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In general, early experience with the first-generation cryoballoon introduced an increase in radiation exposure as compared to traditional radiofrequency ablations for atrial fibrillation (AF). However, through operator vigilance and the incorporation of various techniques and technologies, procedural radiation exposure can be managed to an exceptionally low level while maintaining the safety and efficacy of the cryoballoon procedure. METHODS AND RESULTS A retrospective chart review of all consecutive AF ablation procedures performed by a single operator at a single high-volume center with the second-generation cryoballoon (Arctic Front Advance) was performed between 2014 and 2017. Procedural and radiation exposure data were collected and analyzed year-over-year. 307 cases were reviewed with the majority as index procedures (95%) and patients presenting in paroxysmal AF (87%). The observed median absorbed dose was 2.4 mGy (interquartile range (IQR) = 1.0,6.2) and decreased significantly from 6.7 mGy (IQR = 1.6,6.2) in 2014 to 2.0 mGy (IQR = 1.5,4.5) in 2017 (P < 0.001). Median fluoroscopy time was 0.4 min (IQR = 0.25,0.75) and demonstrated reductions from 0.75 min (IQR = 0.40,1.4) in 2014 to 0.20 min (IQR = 0.10,0.40) in 2017 (P < 0.001). No radiopaque contrast agent was used in any procedure. A complication rate of 2% (6 total events) was observed, and no cases resulted in stroke, death, permanent phrenic nerve injury, or pulmonary vein stenosis. In total, 304 of 307 (99%) procedures resulted in complete isolation of all pulmonary veins. CONCLUSION Ultra-low radiation doses and contrast-free procedures can be achieved as part of an overall "safety-first" approach during cryoballoon AF ablation without compromising safety or acute efficacy.
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Affiliation(s)
- James Reiss
- PeaceHealth Southwest Medical Center Heart & Vascular, Washington, USA.
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Aksu T, Yalin K, Guler TE, Bozyel S, Heeger CH, Tilz RR. Acute Procedural Complications of Cryoballoon Ablation: A Comprehensive Review. J Atr Fibrillation 2019; 12:2208. [PMID: 32435335 DOI: 10.4022/jafib.2208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/14/2019] [Accepted: 08/26/2019] [Indexed: 12/15/2022]
Abstract
Catheter ablation is increasingly performed for treatment of atrial fibrillation (AF). Balloon based procedures have been developed aiming at safer, easier and more effective treatment as compared to point to point ablation. In the present review article, we aimed to discuss acute procedural complications of cryoballoon ablation.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Kivanc Yalin
- Istanbul University- Cerrahpasa, Faculty of Medicine, Department of Cardiology, Istanbul, Turkey.,University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Tumer Erdem Guler
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Serdar Bozyel
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Christian-H Heeger
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Roland R Tilz
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
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12
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Sugrue A, Vaidya V, Yasin O, Isath A, Abudan A, Padmanabhan D, Kapa S, Asirvatham SJ. Development of a novel ablation hood to prevent systemic embolization of microbubbles and particulate emboli. J Interv Card Electrophysiol 2019; 58:281-288. [PMID: 31372780 DOI: 10.1007/s10840-019-00595-y] [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] [Received: 04/30/2019] [Accepted: 07/11/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atrial fibrillation ablation results in microbubbles and particulate emboli formation. We aimed to develop and test the early feasibility of a novel ablation hood to contain microbubbles and particulate emboli with the ultimate goal of preventing systemic embolization. METHODS In seven canines, we developed, iterated, and tested a novel retractable hood that can cover the catheter-tissue ablation site. The number and volume (nL) of microbubbles formed during ablation with and without the hood was measured using an extracorporeal circulation loop. Wilcoxon's signed-rank test was used to compare the number of bubbles detected with and without the hood. RESULTS The hood reduced systemic embolization of microbubbles in 21/28 (75%) of ablations. Both atrial and ventricular ablations showed a statistically significant reduction in bubble number (476 ± 811 without hood vs 173 ± 226 with hood, p = 0.02; 2669 ± 1623 without hood vs 1417 ± 970 with hood, p = 0.04, respectively) and bubble volume (3.3 ± 7.6 nL without hood vs 0.2 ± 0.56 nL with hood, p = 0.006; 6.1 ± 5.2 nL without hood vs 1.9 ± 1.4 nL with hood, p = 0.05, respectively). CONCLUSIONS Use of a novel hood to cover the ablation catheter at the site of catheter-tissue contact has the potential to provide a means to reduce systematic embolization of microbubbles. Further work is required to examine particulate emboli, but these data show the early feasibility of this design concept.
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Affiliation(s)
- Alan Sugrue
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vaibhav Vaidya
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Omar Yasin
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ameesh Isath
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anas Abudan
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Deepak Padmanabhan
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Suraj Kapa
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samuel J Asirvatham
- Division of Heart Rhythm, Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA. .,Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA.
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Nakamura R, Okishige K, Shigeta T, Nishimura T, Kurabayashi M, Yamauchi Y, Sasano T, Hirao K. Clinical comparative study regarding interrupted and uninterrupted dabigatran therapy during perioperative periods of cryoballoon ablation for paroxysmal atrial fibrillation. J Cardiol 2019; 74:150-155. [DOI: 10.1016/j.jjcc.2019.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/08/2019] [Accepted: 02/11/2019] [Indexed: 11/24/2022]
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Ströker E, De Greef Y, Schwagten B, Kupics K, Coutiño HE, Takarada K, Abugattas JP, Salghetti F, De Cocker J, Stockman D, Sieira J, Brugada P, Chierchia GB, de Asmundis C. Over-the-needle trans-septal access using the cryoballoon delivery sheath and dilator in atrial fibrillation ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:868-873. [PMID: 31037747 DOI: 10.1111/pace.13709] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 04/08/2019] [Accepted: 04/24/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the setting of second-generation cryoballoon (CB2) ablation, left atrial (LA) access is generally achieved using a standard sheath (SS) that is exchanged for the 15Fr cryoballoon delivery sheath (CBS) and dilator over a long wire (CBS over-the-wire technique, CBS-W). Our objective was to evaluate the direct use of the CBS to gain LA access, by advancing the latter over the trans-septal needle (CBS over-the-needle technique, CBS-N), under transesophageal echocardiographic (TEE) guidance. METHODS Consecutive patients who underwent CB2 ablation with the CBS-N technique were evaluated for feasibility of gaining LA access using TEE guidance and fluoroscopy views. Complications related to the LA access were compared with a matched CBS-W control group. Subanalysis (30 CBS-W vs 30 CBS-N patients) evaluated time-to-LA of the CBS: time from superior vena cava (with SS vs CBS) to LA insertion of the CBS, after exchange or directly, respectively. RESULTS LA access could be achieved in all 505 patients of the CBS-N group, without technique modification or additional equipment. Challenging interatrial septa were noted in 13% of these patients: previous atrial septal defect repair (1%), hypermobile (10%), aneurysmal (1%), and abnormally thickened/fibrotic (1%). Incidence of complications was similar to the CBS-W group. Subanalysis showed a shorter time-to-LA in the CBS-N versus CBS-W group, 72 ± 46 seconds versus 293 ± 180 seconds, P < .001. CONCLUSIONS Our study showed that the CBS-N technique is feasible and safe under echocardiographic guidance. Without sheath exchange, it simplifies the CB2 procedure, is less costly, time sparing, and might reduce the risk of air embolism.
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Affiliation(s)
- Erwin Ströker
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Electrophysiology Unit, ZNA Middelheim, Antwerp, Belgium
| | - Yves De Greef
- Electrophysiology Unit, ZNA Middelheim, Antwerp, Belgium
| | | | - Kaspars Kupics
- Electrophysiology Unit, ZNA Middelheim, Antwerp, Belgium
| | - Hugo Enrique Coutiño
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Ken Takarada
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Juan Pablo Abugattas
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Francesca Salghetti
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - Dirk Stockman
- Electrophysiology Unit, ZNA Middelheim, Antwerp, Belgium
| | - Juan Sieira
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Pedro Brugada
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
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Techniques for reducing air bubble intrusion into the left atrium during radiofrequency catheter and cryoballoon ablation procedures: An ex vivo study with a high-resolution camera. Heart Rhythm 2019; 16:128-139. [DOI: 10.1016/j.hrthm.2018.07.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Indexed: 11/22/2022]
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16
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Nakamura K, Sasaki T, Take Y, Okazaki Y, Inoue M, Motoda H, Miki Y, Niijima K, Yamashita E, Koyama K, Funabashi N, Naito S. Postablation cerebral embolisms in balloon-based atrial fibrillation ablation with periprocedural direct oral anticoagulants: A comparison between cryoballoon and HotBalloon ablation. J Cardiovasc Electrophysiol 2018; 30:39-46. [PMID: 30288849 DOI: 10.1111/jce.13762] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/19/2018] [Accepted: 09/25/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION This prospective observational study aimed to investigate the incidence of symptomatic and silent cerebral embolisms after balloon-based ablation of atrial fibrillation (AF) in patients receiving periprocedural anticoagulation with direct oral anticoagulants (DOACs), and compare that between cryoballoon and HotBalloon ablation (CBA and HBA). METHODS AND RESULTS We enrolled 123 consecutive AF patients who underwent a balloon-based pulmonary vein isolation (PVI) and brain magnetic resonance (MR) imaging after the ablation procedure (CBA, n = 65; HBA, n = 58). The DOACs were continued in 62 patients throughout the periprocedural period and discontinued in 61 on the procedural day. Intravenous heparin was infused to maintain an activated clotting time of 300 to 400 seconds during the procedure. No symptomatic embolisms occurred in this series. Silent cerebral ischemic lesions (SCILs) were observed on MR imaging in 22 patients (17.9%), and the incidence of SCILs did not significantly differ between the CBA and HBA groups (21.5 vs 13.8%; P = 0.263). According to a multivariate logistic regression analysis, an older age was an independent positive predictor of SCILs (odds ratio, 1.062; 95% CI, 1.001-1.126; P = 0.046), but neither the balloon catheter type nor periprocedural continuation or discontinuation of the DOACs were significant predictors. The incidence of major and minor bleeding complications was comparable between the CBA and HBA groups (1.5 vs 0%, P = 0.528; 7.7 vs 5.2%, P = 0.424). CONCLUSIONS Both CBA and HBA of AF revealed a similar incidence of postablation cerebral embolisms. Elderly patients may be at a risk of SCILs after a balloon-based PVI with periprocedural DOAC treatment.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yoshinori Okazaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Mitsuho Inoue
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Hiroyuki Motoda
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Katsura Niijima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
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Miyazaki S, Kajiyama T, Yamao K, Hada M, Yamaguchi M, Nakamura H, Hachiya H, Tada H, Hirao K, Iesaka Y. Silent cerebral events/lesions after second-generation cryoballoon ablation: How can we reduce the risk of silent strokes? Heart Rhythm 2018; 16:41-48. [PMID: 30017816 DOI: 10.1016/j.hrthm.2018.07.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) ablation is associated with a substantial risk of silent cerebral events/lesions (SCEs/SCLs) detected on magnetic resonance imaging (MRI). OBJECTIVE The purpose of this study was to investigate the factors associated with the incidence of SCEs/SCLs during second-generation cryoballoon ablation. METHODS Two hundred fifty-six AF patients underwent brain MRI 1 day after pulmonary vein (PV) isolation using second-generation cryoballoons with a single 28-mm balloon and short freeze strategy. RESULTS Overall, 991 of 1016 PVs (97.5%) were successfully isolated by 4.9 ± 1.3 cryoballoon applications per patient, and 25 PVs required touch-up radiofrequency ablation. The total procedure time was 72.7 ± 26.1 minutes. SCEs and SCLs were detected in 68 (26.5%) and 27 (10.5%) patients, respectively. None of the patients reported any neurologic symptoms. Reinsertion of once withdrawn cryoballoons and subsequent applications significantly increased the incidence of SCEs (odds ratio [OR] 2.057; 95% confidential interval [CI] 1.051-4.028; P = .035), and additional left atrial mapping with a multielectrode catheter significantly increased the incidence of SCLs (OR 3.317; 95% CI 1.365-8.056; P = .008). Transient coronary air embolisms were significantly associated with the incidence of SCLs (OR 3.447; 95% CI 1.015-11.702; P = 0.047). On the contrary, an uninterrupted anticoagulation regimen, use of radiofrequency deliveries for transseptal access, cryoballoon air removal with extracorporeal balloon inflations, strength of the MRI magnet, internal electrical cardioversion, and touch-up ablation were not associated with the incidence of SCEs/SCLs. CONCLUSION A significant number of SCE/SCL occurrences was observed after second-generation cryoballoon ablation procedures. These results suggest that air embolisms are the main mechanism of SCEs/SCLs, and the injected air volume might determine the lesion type.
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Affiliation(s)
- Shinsuke Miyazaki
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan.
| | - Takatsugu Kajiyama
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Kazuya Yamao
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Masahiro Hada
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Masao Yamaguchi
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hiroaki Nakamura
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hitoshi Hachiya
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hiroshi Tada
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Kenzo Hirao
- Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshito Iesaka
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
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