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Gkalapis C, Vlachos K, Papadakis M, Pavleros N, Hippe HJ, Benali K, Bazoukis G, Letsas KP, Frontera A, Jais P, Gotzmann M. Analysis of the effectiveness of the latest 4th-generation cryoballoon catheters in pulmonary vein isolation using high-resolution mapping. Hellenic J Cardiol 2024:S1109-9666(24)00081-2. [PMID: 38663567 DOI: 10.1016/j.hjc.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 03/23/2024] [Accepted: 04/13/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND Long-term data showed that up to 27% of pulmonary veins are reconnected using cryoballoon ablation. This study aimed to evaluate the efficacy of the latest 4th-generation cryoballoon catheters using ultra high-resolution mapping. METHODS In patients with atrial fibrillation, a standard pulmonary vein isolation (PVI) with the latest 4th-generation cryoballoon catheter (Arctic Front Advance PRO, Medtronic Minneapolis, USA) and the spiral mapping catheter (Achieve Advance, Medtronic, Minneapolis, MN, USA) was performed. Subsequently, high-resolution mapping was achieved using the novel multipolar grid mapping catheter (Advisor HD Grid SE, Abbott Laboratories, USA). Follow-up was obtained after 6 months by means of a 7-day Holter electrocardiogram. RESULTS In our study, acute PVI was successfully achieved in all 31 patients. The latest 4th-generation cryoballoon catheter is safe in the acute phase of PVI. Additional high-resolution mapping (mean points per map 21,001 ± 4911) using the multipolar grid mapping catheter enabled us to identify residual gaps only in the carina pulmonary vein region; therefore, no additional ablation was performed. Three of 31 patients (10%) presented with atrial arrhythmia recurrence always related with pulmonary vein reconnection; using high-resolution mapping had no additional benefit in identifying pulmonary veins in which reconnection will occur. CONCLUSION The utility of additional high-density mapping, facilitated by the HD Grid catheter after PVI with the 4th-generation cryoballoon catheter do not substantiate a discernible advantage over conventional mapping methodologies, particularly, the spiral mapping catheter. Residual carinal conduction was observed in a substantial cohort of patients (48%), highlighting a persistent challenge in achieving complete electrical isolation.
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Affiliation(s)
- Charis Gkalapis
- Department of Cardiology, Marien-Hospital Witten, Ruhr University Bochum, Germany; Department of Cardiology, Klinikum Vest, Recklinghausen, Germany.
| | - Konstantinos Vlachos
- Department of Cardiology, Klinikum Vest, Recklinghausen, Germany; Cardiac Pacing and Electrophysiology Department, Hopital Cardiologique du Haut Léveque, Pessac, France; INSERM U1045, IHU-L'institut de Rythmologie et Modélisation Cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Marios Papadakis
- Department of Surgery II, University of Witten/Herdecke, Wuppertal, Germany
| | - Nikonas Pavleros
- Department of Cardiology, Marien-Hospital Witten, Ruhr University Bochum, Germany; Department of Cardiology, Klinikum Vest, Recklinghausen, Germany
| | - Hans-Jörg Hippe
- Department of Cardiology, Marien-Hospital Witten, Ruhr University Bochum, Germany
| | - Karim Benali
- INSERM U1045, IHU-L'institut de Rythmologie et Modélisation Cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - George Bazoukis
- Department of Cardiology, Larnaca General Hospital, Larnaca, Cyprus; European University Cyprus, Medical School, Nicosia, Cyprus
| | | | | | - Pierre Jais
- Cardiac Pacing and Electrophysiology Department, Hopital Cardiologique du Haut Léveque, Pessac, France; INSERM U1045, IHU-L'institut de Rythmologie et Modélisation Cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
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Bohnen M, Weber R, Minners J, Jadidi A, Eichenlaub M, Neumann FJ, Arentz T, Lehrmann H. Characterization of circumferential antral pulmonary vein isolation areas resulting from pulsed-field catheter ablation. Europace 2023; 25:65-73. [PMID: 35852306 PMCID: PMC10103571 DOI: 10.1093/europace/euac111] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS The cornerstone of pulmonary vein (PV) isolation (PVI) is a wide-area circumferential ablation (WACA) resulting in an antral PVI area. Pulsed-field ablation (PFA) is a new nonthermal 'single-shot' PVI technique resulting in well-characterized posterior isolation areas. However, information on circumferential PVI area is lacking. Thus, we sought to characterize the circumferential antral PVI areas after PFA-PVI. METHODS AND RESULTS Atrial fibrillation (AF) patients underwent fluoroscopy-guided PVI with a pentaspline PFA catheter. Ultra-high-density voltage maps using a 20-polar circular mapping catheter were created before and immediately after PVI to identify and quantify (i) insufficient isolation areas per antral PV segment (10-segment model) and (ii) enlarged left atrial (LA) isolation areas (beyond the antral PV segments) per LA region (8-region model). The PFA-PVI with pre- (5469 ± 1822 points) and post-mapping (6809 ± 2769 points) was performed in 40 consecutive patients [age 62 ± 6 years, 25/40 (62.5%) paroxysmal AF]. Insufficient isolation areas were located most frequently in the anterior antral PV segments of the left PVs (62.5-77.5% of patients) with the largest extent (median ≥0.4 cm2) located in the same segments (segments 2/5/8). Enlarged LA isolation areas were located most frequently and most extensively on the posterior wall and roof region (89.5-100% of patients; median 1.1-2.7 cm2 per region). CONCLUSION Fluoroscopy-guided PFA-PVI frequently results in insufficient isolation areas in the left anterior antral PV segments and enlarged LA isolation areas on the posterior wall/roof, which both may be extensive. To optimize the procedure, full integration of PFA catheter visualization into three-dimensional-mapping systems is needed.
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Affiliation(s)
- Marius Bohnen
- Department of Cardiology and Angiology II (Campus Bad Krozingen), Heart Center, University Hospital Freiburg, Südring 15, 79189 Bad Krozingen, Germany
| | - Reinhold Weber
- Department of Cardiology and Angiology II (Campus Bad Krozingen), Heart Center, University Hospital Freiburg, Südring 15, 79189 Bad Krozingen, Germany
| | - Jan Minners
- Department of Cardiology and Angiology II (Campus Bad Krozingen), Heart Center, University Hospital Freiburg, Südring 15, 79189 Bad Krozingen, Germany
| | - Amir Jadidi
- Department of Cardiology and Angiology II (Campus Bad Krozingen), Heart Center, University Hospital Freiburg, Südring 15, 79189 Bad Krozingen, Germany
| | - Martin Eichenlaub
- Department of Cardiology and Angiology II (Campus Bad Krozingen), Heart Center, University Hospital Freiburg, Südring 15, 79189 Bad Krozingen, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II (Campus Bad Krozingen), Heart Center, University Hospital Freiburg, Südring 15, 79189 Bad Krozingen, Germany
| | - Thomas Arentz
- Department of Cardiology and Angiology II (Campus Bad Krozingen), Heart Center, University Hospital Freiburg, Südring 15, 79189 Bad Krozingen, Germany
| | - Heiko Lehrmann
- Department of Cardiology and Angiology II (Campus Bad Krozingen), Heart Center, University Hospital Freiburg, Südring 15, 79189 Bad Krozingen, Germany
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Del Monte A, Pannone L, Bisignani A, Osório TG, Iacopino S, Chierchia GB, de Asmundis C. Cryoballoon ablation for atrial fibrillation: Effects on neuromodulation. Front Cardiovasc Med 2022; 9:958316. [PMID: 35966567 PMCID: PMC9366392 DOI: 10.3389/fcvm.2022.958316] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022] Open
Abstract
Pulmonary vein isolation (PVI) represents the mainstay of atrial fibrillation (AF) ablation, and PVI with cryoballoon catheter (CB) ablation (CB-A) has proven to be as effective and safe as radiofrequency ablation (RF-A). Although AF is initiated by triggers arising from the pulmonary veins (PV) and non-PV foci, the intrinsic cardiac nervous system (ICNS) plays a significant role in the induction and maintenance of AF. The ICNS is an epicardial neural system composed of ganglionated plexi (GPs) and a complex network of interconnecting neurons. In the left atrium, the major GPs are located in proximity to the PV-left atrial junction. Vagal reactions have been described as markers of autonomic modulation during PVI with both RF-A and CB-A. The occurrence of neuromodulation during PVI with CB-A may be explained by both the anatomical relationship between the GPs and the PVs and the characteristics of the CB. Due to the CB/PV size mismatch, the CB creates a wide ablation area that extends from the PV ostium toward the antrum, possibly including the GPs. Although targeted GPs ablation, as a supplemental strategy to PVI, has been associated with a better AF outcome in patients undergoing RF-A, the additional clinical benefit of neuromodulation during PVI with CB-A remains a matter of debate. In this review, we provide an overview of the anatomy of the ICNS, the relationship between the ICNS and AF pathophysiology, and the current evidence on the clinical relevance of neuromodulation during PVI with CB-A.
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Affiliation(s)
- Alvise Del Monte
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Antonio Bisignani
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Thiago G. Osório
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Saverio Iacopino
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
- Arrhythmology Department, Maria Cecilia Hospital, Cotignola, Italy
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
- *Correspondence: Gian-Battista Chierchia
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
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Hartley A, Shalhoub J, Ng FS, Krahn AD, Laksman Z, Andrade JG, Deyell MW, Kanagaratnam P, Sikkel MB. Size matters in atrial fibrillation: the underestimated importance of reduction of contiguous electrical mass underlying the effectiveness of catheter ablation. Europace 2021; 23:1698-1707. [PMID: 33948648 PMCID: PMC8576280 DOI: 10.1093/europace/euab078] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
Evidence has accumulated over the last century of the importance of a critical electrical mass in sustaining atrial fibrillation (AF). AF ablation certainly reduces electrically contiguous atrial mass, but this is not widely accepted to be an important part of its mechanism of action. In this article, we review data showing that atrial size is correlated in many settings with AF propensity. Larger mammals are more likely to exhibit AF. This is seen both in the natural world and in animal models, where it is much easier to create a goat model than a mouse model of AF, for example. This also extends to humans-athletes, taller people, and obese individuals all have large atria and are more likely to exhibit AF. Within an individual, risk factors such as hypertension, valvular disease and ischaemia can enlarge the atrium and increase the risk of AF. With respect to AF ablation, we explore how variations in ablation strategy and the relative effectiveness of these strategies may suggest that a reduction in electrical atrial mass is an important mechanism of action. We counter this with examples in which there is no doubt that mass reduction is less important than competing theories such as ganglionated plexus ablation. We conclude that, when considering future strategies for the ablative therapy of AF, it is important not to discount the possibility that contiguous electrical mass reduction is the most important mechanism despite the disappointing consequence being that enhancing success rates in AF ablation may involve greater tissue destruction.
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Affiliation(s)
- Adam Hartley
- National Heart and Lung Institute,Imperial College London, London, UK
| | - Joseph Shalhoub
- National Heart and Lung Institute,Imperial College London, London, UK
| | - Fu Siong Ng
- National Heart and Lung Institute,Imperial College London, London, UK
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | - Zachary Laksman
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | - Jason G Andrade
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | - Marc W Deyell
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | | | - Markus B Sikkel
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
- Division of Medical Sciences, University of Victoria, Victoria, Canada
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Left Atrial Fibrosis after Single Shot Guided Pulmonary Vein Isolation. J Clin Med 2021; 10:jcm10194478. [PMID: 34640495 PMCID: PMC8509823 DOI: 10.3390/jcm10194478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 11/16/2022] Open
Abstract
Cryoballoon (CB)-based pulmonary vein isolation (PVI) is an effective treatment modality for patients with atrial fibrillation (AF) with encouraging acute and long-term outcome data. However, the size of collaterally created lesion sets adjacent to the pulmonary veins (PVs) remains unclear, especially when CB ablation is performed with individualized time-to-isolation (TTI) protocols. This study seeks to investigate the extension of lesions at the posterior wall and the roof of the left atrium (LA). Thirty patients with paroxysmal or persistent AF underwent ablation with a fourth-generation CB. The individual freeze-cycle duration was set at TTI + 120 s. A total of 120 PVs were identified, and all were successfully isolated. A three-dimensional electroanatomical high-density (HD) mapping of the LA was performed in every patient before and after PVI. The surface areas of the posterior wall and LA roof were measured and compared with lesion extension after PVI. After CB ablation, 65.6 ± 16.9% of the posterior wall and 75.4 ± 18.4% of the LA roof remained unablated. In addition, non-antral lesion formation was observed in every patient in at least one PV. After CB ablation, anterior antral parts of the superior PVs showed the greatest unablated areas compared with the other antral areas. HD re-mapping after CB-based PVI demonstrated that major regions of the posterior wall and roof remained electrically normal and unaffected. Unablated antral areas were localized predominantly in the anterior segments of the superior PVs and may be partly responsible for AF recurrence.
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6
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Aryana A. Rationale and Outcomes of Cryoballoon Ablation of the Left Atrial Posterior Wall in Conjunction with Pulmonary Vein Isolation. J Innov Card Rhythm Manag 2021; 12:4633-4646. [PMID: 34476116 PMCID: PMC8384303 DOI: 10.19102/icrm.2021.120801] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/15/2021] [Indexed: 12/12/2022] Open
Abstract
There is strong evidence in support of pulmonary vein isolation (PVI) with concomitant left atrial (LA) posterior wall (PW) isolation (PWI) for the treatment of patients with persistent atrial fibrillation (persAF). While this may be achieved using surgical and catheter-based strategies, there is growing interest in performing this approach using the cryoballoon. There are several potential advantages to this strategy. First, lesions created using the current-generation cryoballoons are typically large and durable. Second, cryoballoon ablation offers a simple technique to directly ablate and debulk the LAPW. Moreover, some consider cryoenergy a safer modality specifically with regard to collateral structures (ie, the esophagus). Based on the available data, cryoballoon PVI + PWI is associated with greater intraprocedural AF terminations and reductions in long-term AF recurrence (typically by ~20%), as compared to PVI alone in patients with persAF, but with similar rates of adverse events. As such, PVI + PWI has emerged as a significant predictor of freedom from recurrent AF (odds ratio: 3.67, 95% confidence interval: 1.44-9.34; p = 0.006) as well as all atrial arrhythmias (hazard ratio: 2.04, 95% confidence interval: 1.15-3.61; p = 0.015). Adjunct radiofrequency ablation to complete PWI is required in at least one-third of the patients, and this need is highly predicted by the LA size (significantly increased with an LA diameter > 48 mm). LAPW reconnection also seems to be associated with LA dimension, particularly an LA diameter greater than 48 mm (negative predictive value: 89.7%). Nevertheless, based on the analysis of patients who underwent repeat electrophysiology study for arrhythmia recurrences, cryoballoon PVI + PWI yields acceptable long-term durability (> 80%).
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Affiliation(s)
- Arash Aryana
- Dignity Health Heart and Vascular Institute, Sacramento, CA, USA
- Cardiac Catheterization Laboratory, Mercy General Hospital, Sacramento, CA, USA
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Aryana A, Su W, Kuniss M, Okishige K, de Asmundis C, Tondo C, Chierchia GB. Segmental nonocclusive cryoballoon ablation of pulmonary veins and extrapulmonary vein structures: Best practices III. Heart Rhythm 2021; 18:1435-1444. [PMID: 33905811 DOI: 10.1016/j.hrthm.2021.04.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 11/19/2022]
Abstract
Although cryoballoon ablation of atrial fibrillation (AF) traditionally has been guided by pulmonary vein (PV) occlusion, there is evidence and growing interest in performing segmental, nonocclusive cryoballoon ablation to target not only large/common PVs but extra-PV structures such as the left atrial (LA) roof and posterior wall in conjunction with PV isolation. A number of studies have demonstrated improved clinical efficacy associated with nonocclusive cryoballoon ablation of the LA roof and posterior wall in addition to PV isolation, particularly in patients with persistent AF. Not only can the cryoballoon be used for targeting extra-PV structures through segmental, nonocclusive ablation, but the large size and durability of cryolesions coupled with the enhanced stability afforded through cryoadhesion render the cryoballoon an effective tool for such an approach. This article reviews the rationale and practical approach to segmental, nonocclusive cryoballoon ablation of large/common PV antra and the LA roof and posterior wall.
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Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California.
| | - Wilber Su
- Banner University Medical Center, Phoenix, Arizona
| | - Malte Kuniss
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
| | - Kaoru Okishige
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | | | - Claudio Tondo
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS; Department of Biochemical, Surgical and Dental Sciences, University of Milan, Milan, Italy
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Bisignani A, Overeinder I, Kazawa S, Iacopino S, Cecchini F, Miraglia V, Osório TG, Boveda S, Bala G, Mugnai G, Monaco C, Ströker E, Brugada P, Sieira J, Galli A, de Asmundis C, Chierchia GB. Posterior box isolation as an adjunctive ablation strategy with the second-generation cryoballoon for paroxysmal atrial fibrillation: a comparison with standard cryoballoon pulmonary vein isolation. J Interv Card Electrophysiol 2020; 61:313-319. [DOI: 10.1007/s10840-020-00812-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
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Aryana A, Chierchia GB, de Asmundis C. Recurrent Atrial Fibrillation After Cryoballoon Ablation: What to Expect! Card Electrophysiol Clin 2020; 12:199-208. [PMID: 32451104 DOI: 10.1016/j.ccep.2020.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation (AF) recurrence following cryoballoon ablation may occur as a consequence of pulmonary vein (PV) reconnection, which can be treated effectively by performing repeat PV isolation. Alternatively, AF recurrence can manifest in presence of bilateral antral PV isolation. In such circumstances, one may pursue catheter ablation of AF triggers, if present, or proceed with empiric posterior left atrial wall ablation. Although traditionally, focal radiofrequency ablation has been used for this, cryoballoon ablation, itself, may also be used for ablation/isolation of certain structures such as the superior vena cava, the left atrial appendage and even the posterior left atrial wall.
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Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Suite #350, 3941 J Street, Sacramento, CA 95819, USA.
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Strategies to Improve the Outcome of Cryoballoon Ablation in the Treatment of Atrial Fibrillation. BIOMED RESEARCH INTERNATIONAL 2020; 2020:6720481. [PMID: 32337265 PMCID: PMC7166274 DOI: 10.1155/2020/6720481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 03/24/2020] [Indexed: 11/18/2022]
Abstract
Atrial fibrillation (AF) is a common arrhythmia contributing to severe outcomes, including cardiac dysfunction and stroke, and it has drawn great attention around the world. Drug therapies have been available for many years to terminate AF and control heart rate. However, the results from clinical studies on drug therapies have been discouraging. Mounting evidence indicates that radiofrequency catheter ablation (RFCA) is a safe and effective method to maintain sinus rhythm, especially in patients who are drug intolerant or for whom the drugs are ineffective, although it is a technically demanding and complex procedure. Fortunately, a novel application, cryoballoon ablation (CBA), with outstanding characteristics has been widely used. Great outcomes based on CBA have manifested its significant role in the treatment of AF. However, how to improve the safety and efficacy of CBA is a question that has not been well-answered. Would it be helpful to develop a different generation of cryoballoon? Is bonus freezing beneficial, or not? Is it better to prolong freezing time? Dose CBA combined with RFCA bring higher success rates? In this review, we comprehensively summarized useful applications for improving outcomes of CBA in AF patients.
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11
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Andrade JG. Cryoballoon ablation for pulmonary vein isolation. J Cardiovasc Electrophysiol 2020; 31:2128-2135. [PMID: 32239557 DOI: 10.1111/jce.14459] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/04/2020] [Indexed: 11/30/2022]
Abstract
Over the past 20 years, multiple studies have demonstrated the superiority of percutaneous catheter-based pulmonary vein isolation (PVI) in the management of atrial fibrillation (AF). Unfortunately, the results of catheter ablation can be limited by arrhythmia recurrence, which is often a result of a failure to achieve durable lesions around the pulmonary vein ostia. In response, significant efforts have been directed toward developing technologies to achieve safer and more durable PVI, including the development of dedicated catheters capable of achieving PVI with a single ablation lesion (eg, the Arctic Front Cryoballoon; Medtronic CryoCath, Pointe-Claire, Canada). The purpose of this review is to discuss the contemporary role of cryoballoon ablation in the invasive management of AF, with a focus on the characteristics that differentiate cryoballoon from radiofrequency ablation.
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Affiliation(s)
- Jason G Andrade
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada.,Heart Rhythm Services, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Center for Cardiovascular Innovation, Vancouver, British Columbia, Canada
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12
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Miyazaki S, Horie T, Hachiya H, Hasegawa K, Kajiyama T, Watanabe T, Nakamura H, Ishikawa E, Mukai M, Aoyama D, Nodera M, Kaseno K, Iesaka Y, Tada H. The mechanisms of recurrent atrial arrhythmias after second-generation cryoballoon ablation. Am Heart J 2020; 221:29-38. [PMID: 31901798 DOI: 10.1016/j.ahj.2019.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/06/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND In patients with paroxysmal atrial fibrillation (PAF), 10%-15% of patients require repeat procedures after second-generation cryoballoon pulmonary vein isolation (CB-PVI). We sought to explore the mechanisms of recurrences after cryoballoon ablation. METHODS The data of 122 PAF patients who underwent second procedures for recurrent arrhythmias 7.0 (4.0-12.0) months after the CB-PVI were analyzed. During second procedures, non-PV AF foci were explored with isoproterenol, adenosine, and repetitive cardioversions. RESULTS In total, 378/487 (77.6%) PVs remained isolated, and reconnections were not observed in any PVs in 59 (48.4%) patients. PV reconnections were associated with recurrences in 38 (31.1%) patients, of whom 33 (86.8%) had reconnections of at least 1 upper PV. In 6 (4.9%) patients, non-PV AF foci were identified in the upper PV antra where cryoballoons cannot isolate but within the circumferential radiofrequency PVI line. Non-PV AF foci were identified in the superior vena cava, right atrial body, left atrial body, and atrial septum in 28 (23.0%), 18 (14.7%), 4 (3.3%), and 5 (4.1%) patients, respectively. Twelve (9.8%) patients had multiple non-PV AF foci. Four (3.3%), 3 (2.4%), and 8 (6.5%) patients underwent second procedures for atrioventricular nodal reentrant tachycardia, atrial flutter, and atrial tachycardias. During 16.0 (8.0-24.0) months of follow-up, freedom from any atrial arrhythmia at 1 year and 2 years after the second procedure was 79.2% and 60.6%. Nineteen (15.5%) patients had antiarrhythmic drug therapy at the last follow-up. CONCLUSIONS Our study suggested that improvement in the upper PV PVI durability, eliminating arrhythmogenic superior vena cavae and coexisting atrial arrhythmias, and bonus cryoballoon applications at PV antra might improve the single procedure outcome in cryoballoon ablation.
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Affiliation(s)
- Shinsuke Miyazaki
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan.
| | - Tomoki Horie
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hitoshi Hachiya
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Kanae Hasegawa
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Takatsugu Kajiyama
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Tomonori Watanabe
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hiroaki Nakamura
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Eri Ishikawa
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Moe Mukai
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Daisetsu Aoyama
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Minoru Nodera
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Kenichi Kaseno
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Yoshito Iesaka
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hiroshi Tada
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
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Te ALD, Lo LW, Lin YJ, Chang SL, Hu YF, Chung FP, Tuan TC, Chao TF, Liao JN, Chang YT, Lin CY, Yamada S, Chang TY, Salim S, Hoang MQ, Huang TC, Chen SA. Vasovagal responses during cryoballoon pulmonary vein isolation in paroxysmal atrial fibrillation predict favorable mid-term outcomes. Int J Cardiol 2018; 258:115-120. [DOI: 10.1016/j.ijcard.2018.01.111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/27/2017] [Accepted: 01/23/2018] [Indexed: 11/28/2022]
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Chikata A, Kato T, Usuda K, Fujita S, Maruyama M, Nagata Y, Sakagami S, Kanamori N, Yaegashi T, Saeki T, Kusayama T, Usui S, Furusho H, Kaneko S, Takamura M. Impact of left atrial size on isolation area in the acute phase of pulmonary vein isolation using 28 mm cryoballoon. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:700-706. [PMID: 29603755 DOI: 10.1111/pace.13337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 03/19/2018] [Accepted: 03/19/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The impact of left atrial (LA) size on isolation area (ISA) using a 28-mm second-generation cryoballoon (CB) in the acute phase after pulmonary vein isolation (PVI) and the differences of CB from contact force-guided radiofrequency (RF) ablation have not been fully investigated. METHODS We examined 85 consecutive patients (CB group, 35; RF group, 50) with drug-refractory paroxysmal atrial fibrillation who underwent their first PVI procedure at two institutions. We evaluated ISA after PVI using 3D-Merge computed tomography images (GE Healthcare, Little Chalfont, UK) and high-resolution electroanatomical mapping. RESULTS Total ISA was significantly smaller in the CB group (20.6 ± 6.0 cm2 ) than in the RF group (29.0 ± 7.1 cm2 ; P < 0.0001). In the CB group, ISA of the left pulmonary vein (LPV), right pulmonary vein (RPV), and total ISA were not correlated with the left atrial surface area (LASA). The ratios of ISA to LASA (%ISA) of LPV and total ISA negatively correlated with LASA in the CB group (LPV: r = -0.4001, P = 0.0173; total ISA: r = -0.4733, P = 0.0041). In contrast, in the RF group, ISA of LPV, RPV, and total ISA positively correlated with LASA; (LPV: r = 0.5155, P = 0.001; RPV: r = 0.6398, P < 0.0001; total ISA: r = 0.7299, P < 0.0001). CONCLUSION ISA created using CB was significantly smaller than that using RF and did not change regardless of LASA increment. Differences in ISA between the two groups became more prominent in the large atrium.
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Affiliation(s)
- Akio Chikata
- Division of Cardiology, Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan.,Department of Cardiology, National Hospital Organization, Kanazawa Medical Center, Kanazawa, Japan
| | - Takeshi Kato
- Department of System Biology, Kanazawa University Graduate School of Advanced Preventive Medical Sciences, Kanazawa, Japan
| | - Kazuo Usuda
- Division of Cardiology, Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Shuhei Fujita
- Department of Pediatrics, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Michiro Maruyama
- Division of Cardiology, Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Yoshiki Nagata
- Division of Cardiology, Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Satoru Sakagami
- Department of Cardiology, National Hospital Organization, Kanazawa Medical Center, Kanazawa, Japan
| | - Naomi Kanamori
- Department of Cardiology, National Hospital Organization, Kanazawa Medical Center, Kanazawa, Japan
| | - Takanori Yaegashi
- Department of Cardiology, National Hospital Organization, Kanazawa Medical Center, Kanazawa, Japan
| | - Takahiro Saeki
- Department of Cardiology, National Hospital Organization, Kanazawa Medical Center, Kanazawa, Japan
| | - Takashi Kusayama
- Department of System Biology, Kanazawa University Graduate School of Advanced Preventive Medical Sciences, Kanazawa, Japan
| | - Soichiro Usui
- Department of System Biology, Kanazawa University Graduate School of Advanced Preventive Medical Sciences, Kanazawa, Japan
| | - Hiroshi Furusho
- Department of System Biology, Kanazawa University Graduate School of Advanced Preventive Medical Sciences, Kanazawa, Japan
| | - Shuichi Kaneko
- Department of System Biology, Kanazawa University Graduate School of Advanced Preventive Medical Sciences, Kanazawa, Japan
| | - Masayuki Takamura
- Department of System Biology, Kanazawa University Graduate School of Advanced Preventive Medical Sciences, Kanazawa, Japan
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Okumura Y, Watanabe I, Iso K, Takahashi K, Nagashima K, Sonoda K, Mano H, Yamaguchi N, Kogawa R, Watanabe R, Arai M, Ohkubo K, Kurokawa S, Nakai T, Hirayama A. Mechanistic Insights Into Durable Pulmonary Vein Isolation Achieved by Second-Generation Cryoballoon Ablation. J Atr Fibrillation 2017; 9:1538. [PMID: 29250289 DOI: 10.4022/jafib.1538] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/19/2017] [Accepted: 02/24/2017] [Indexed: 11/10/2022]
Abstract
Background The mechanism explaining the efficacy of cryoballoon ablation (CBA) for atrial fibrillation has not been clarified. Methods and Results We compared lesion characteristics between patients in whom pulmonary vein isolation (PVI) was performed by CBA (n=56) and those by contact force (CF)-based RF ablation (n=56). We evaluated the 3-dimensional PV morphology before and after cryoballoon inflation. After PVI, a 3D left atrial voltage map was created. Pacing (10 mA and 2 ms) was performed within the low voltage area from the ablation line, and electrically unexcitable ablated tissue was identified. ATP-provoked dormant conduction after PVI occurred in 9 of the 224 (4%) PVs in the CBA group and in 13 of the 224 (6%) PVs in the CF group (P=0.3935). The inflated balloon stretched the PV from the original PV ostial surface by 7.1±3.5 mm, but at sites with (vs, sites without) residual PV potential/dormant conduction, the extent of the PV distension was reduced (4.0±4.0 mm vs. 7.2±3.4 mm, P<0.0001). The unexcitable ablated tissue around the PVs was significantly wider in CB patients than in CF patients (16.7±5.1 mm vs. 5.3±2.3 mm, P<0.0001). Conclusions Use of the cryoballoon significantly distends the PV. Without this extensive distention, PVI may not be successful. CBA seems to yield wide unexcitable ablation zones. These factors seem to explain the durability of CBA lesions.
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Affiliation(s)
- Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ichiro Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kazuki Iso
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Keiko Takahashi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kazumasa Sonoda
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroaki Mano
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Naoko Yamaguchi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Rikitake Kogawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masaru Arai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Sayaka Kurokawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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Miyazaki S, Taniguchi H, Hachiya H, Nakamura H, Takagi T, Iwasawa J, Hirao K, Iesaka Y. Quantitative Analysis of the Isolation Area During the Chronic Phase After a 28-mm Second-Generation Cryoballoon Ablation Demarcated by High-Resolution Electroanatomic Mapping. Circ Arrhythm Electrophysiol 2016; 9:e003879. [PMID: 27146418 DOI: 10.1161/circep.115.003879] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/29/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND The post-second-generation cryoballoon (CB) ablation isolation area during the chronic phase has not been described. The aim of this study was to quantitatively evaluate the chronic-phase isolation area after 28-mm second-generation CB ablation and compare it to the estimated conventional radiofrequency circumferential pulmonary vein isolation (CPVI) line. METHODS AND RESULTS Thirty-two patients with paroxysmal atrial fibrillation underwent pulmonary vein (PV) isolation using second-generation CB. After a median of 6.0 (4.0-9.0) months, the PV isolation area was evaluated using high-resolution mapping (1-mm electrode, 2-mm interelectrode spacing; 527±99 points per map) and pacing techniques in all patients (17 with and 15 without arrhythmia recurrence beyond blanking period) and compared with estimated conventional radiofrequency CPVI area. PV reconnections were observed in 34 of 126 PVs (27.0%) among 21 of 32 patients (65.6%), which were eliminated by a median of 1.0 (1.0-3.0) focal radiofrequency application. The left- and right-sided PV antrum isolation area and nonablated posterior wall areas were 9.8±1.7, 8.1±2.3, and 17.0±6.1 cm(2), respectively. The cryoablated areas were significantly smaller than the estimated conventional radiofrequency CPVI areas in all but the right inferior PV. The difference was highest in the left superior PV. In 2 patients (6.3%), recurrent atrial fibrillation originated from the foci identified at the left superior PV antrum outside the CB isolation area but inside the estimated conventional radiofrequency CPVI line. CONCLUSIONS Although the PV isolation areas during the chronic phase after the second-generation CB ablation were generally wide, they were significantly smaller than the area encircled by the CPVI line except at the right inferior PV antrum. Recurrent atrial fibrillation could originate from the left superior PV antrum and could be isolated by a CPVI but not by a CB.
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Affiliation(s)
- Shinsuke Miyazaki
- From the Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan (S.M., H.T., H.H., H.N., T.T., J.I., Y.I.); and Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan (K.H.).
| | - Hiroshi Taniguchi
- From the Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan (S.M., H.T., H.H., H.N., T.T., J.I., Y.I.); and Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan (K.H.)
| | - Hitoshi Hachiya
- From the Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan (S.M., H.T., H.H., H.N., T.T., J.I., Y.I.); and Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan (K.H.)
| | - Hiroaki Nakamura
- From the Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan (S.M., H.T., H.H., H.N., T.T., J.I., Y.I.); and Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan (K.H.)
| | - Takamitsu Takagi
- From the Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan (S.M., H.T., H.H., H.N., T.T., J.I., Y.I.); and Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan (K.H.)
| | - Jin Iwasawa
- From the Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan (S.M., H.T., H.H., H.N., T.T., J.I., Y.I.); and Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan (K.H.)
| | - Kenzo Hirao
- From the Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan (S.M., H.T., H.H., H.N., T.T., J.I., Y.I.); and Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan (K.H.)
| | - Yoshito Iesaka
- From the Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan (S.M., H.T., H.H., H.N., T.T., J.I., Y.I.); and Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan (K.H.)
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ZHOU GONGBU, GUO XIAOGANG, LIU XU, YANG JIANDU, SUN QI, MA JIAN, ZHANG SHU. Pulmonary Vein Isolation Using the First-Generation Cryoballoon Technique in Chinese Patients. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1073-81. [PMID: 26096255 DOI: 10.1111/pace.12675] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 05/05/2015] [Accepted: 05/26/2015] [Indexed: 11/30/2022]
Affiliation(s)
- GONG-BU ZHOU
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
| | - XIAO-GANG GUO
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
| | - XU LIU
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
| | - JIAN-DU YANG
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
| | - QI SUN
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
| | - JIAN MA
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
| | - SHU ZHANG
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
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Quantification of the cryoablation zone demarcated by pre- and postprocedural electroanatomic mapping in patients with atrial fibrillation using the 28-mm second-generation cryoballoon. Heart Rhythm 2015; 12:283-90. [DOI: 10.1016/j.hrthm.2014.11.012] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Indexed: 11/20/2022]
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19
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Martí-Almor J, Bazan V. Comments on Long-term results of cryoballoon ablation in the treatment of atrial fibrillation in a low-volume center. Response. ACTA ACUST UNITED AC 2014; 67:1076-7. [PMID: 25449819 DOI: 10.1016/j.rec.2014.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 07/28/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Julio Martí-Almor
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Víctor Bazan
- Unidad de Arritmias, Servicio de Cardiología, Hospital del Mar, Universidad Autónoma de Barcelona, Barcelona, Spain.
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Martí-Almor J, Bazan V. Comentario a resultados a largo plazo de la crioablación con balón para el tratamiento de la fibrilación auricular en un centro de bajo volumen. Respuesta. Rev Esp Cardiol (Engl Ed) 2014. [DOI: 10.1016/j.recesp.2014.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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21
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Rao JY, Chierchia GB, de Asmundis C, Casado-Arroyo R, Overeinder I, Sarkozy A, Paparella G, Capulzini L, Sorgente A, Rodriguez-Manero M, Ricciardi D, Namdar M, Brugada P. Cryoballoon ablation as index procedure for paroxysmal atrial fibrillation: long-term results from a single center early experience. J Cardiovasc Med (Hagerstown) 2014; 15:194-8. [PMID: 23756414 DOI: 10.2459/jcm.0b013e3283623838] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Cryoballoon ablation (CRAB) as a modality for pulmonary vein isolation (PVI) is increasingly being accepted. We aim to study the long-term durability of CRAB in atrial fibrillation. METHODS The first 51 consecutive patients with documented paroxysmal atrial fibrillation(PAF) who underwent CRAB at our institute were considered. Forty patients formed the study group. Successful PVI was achieved in all the patients. Patients were evaluated with Holter ECG recordings at 1, 3, 6 and 12 months and subsequent follow-up was biannual and based on the clinical status and physician discretion whether symptoms occurred. For the study purpose, a baseline ECG, a 24-h Holter and clinical evaluation were performed in all patients at final follow-up. RESULTS A large 28-mm cryoballoon (CB) was used in 38 patients (95%), and the small 23-mm CB in the remaining two individuals (2%). The freedom from atrial fibrillation off-antiarrhythmic drug treatment (AAD) after a single procedure at a mean follow-up of 36.6 ± 4 months was 57.5% (23/40). Transient right phrenic nerve palsy was the most common complication. CONCLUSION Single balloon size CRAB provides a durable atrial fibrillation-free-AAD-free survival in drug-resistant PAF patients over long-term follow-up with a success rate of 57.5% with a single procedure.
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Affiliation(s)
- Jayakeerthi Yoganarasimha Rao
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium *These authors have contributed equally to the manuscript
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AKERSTRÖM FINN, BASTANI HAMID, INSULANDER PER, SCHWIELER JONAS, ARIAS MIGUELA, JENSEN-URSTAD MATS. Comparison of Regular Atrial Tachycardia Incidence After Circumferential Radiofrequency versus Cryoballoon Pulmonary Vein Isolation in Real-Life Practice. J Cardiovasc Electrophysiol 2014; 25:948-952. [DOI: 10.1111/jce.12423] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 03/06/2014] [Accepted: 03/25/2014] [Indexed: 11/30/2022]
Affiliation(s)
- FINN AKERSTRÖM
- Cardiac Arrhythmia and Electrophysiology Unit; Department of Cardiology; Hospital Virgen de la Salud; Toledo Spain
| | - HAMID BASTANI
- Department of Cardiology; Karolinska Institute; Karolinska University Hospital; Stockholm Sweden
| | - PER INSULANDER
- Department of Cardiology; Karolinska Institute; Karolinska University Hospital; Stockholm Sweden
| | - JONAS SCHWIELER
- Department of Cardiology; Karolinska Institute; Karolinska University Hospital; Stockholm Sweden
| | - MIGUEL A. ARIAS
- Cardiac Arrhythmia and Electrophysiology Unit; Department of Cardiology; Hospital Virgen de la Salud; Toledo Spain
| | - MATS JENSEN-URSTAD
- Department of Cardiology; Karolinska Institute; Karolinska University Hospital; Stockholm Sweden
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Mikhaylov EN, Bhagwandien R, Janse PA, Theuns DAMJ, Szili-Torok T. Regular atrial tachycardias developing after cryoballoon pulmonary vein isolation: incidence, characteristics, and predictors. Europace 2013; 15:1710-7. [DOI: 10.1093/europace/eut129] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ferrero-de Loma-Osorio Á, Izquierdo-de Francisco M, Martínez-Brotons A, Sánchez-Gómez JM, Mascarell-Gregori B, Ruiz-Ros V, Cuenca-Romero I, García-Civera R, Chorro-Gascó FJ, Ruiz-Granell R. Medium-term results of cryoballoon ablation of the pulmonary veins in patients with paroxysmal and persistent atrial fibrillation. First experience of a Spanish center. J Interv Card Electrophysiol 2013; 37:189-96. [DOI: 10.1007/s10840-013-9797-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 02/25/2013] [Indexed: 01/05/2023]
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Kosmidou I, Wooden S, Jones B, Deering T, Wickliffe A, Dan D. Direct pressure monitoring accurately predicts pulmonary vein occlusion during cryoballoon ablation. J Vis Exp 2013:e50247. [PMID: 23485956 DOI: 10.3791/50247] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Cryoballoon ablation (CBA) is an established therapy for atrial fibrillation (AF). Pulmonary vein (PV) occlusion is essential for achieving antral contact and PV isolation and is typically assessed by contrast injection. We present a novel method of direct pressure monitoring for assessment of PV occlusion. Transcatheter pressure is monitored during balloon advancement to the PV antrum. Pressure is recorded via a single pressure transducer connected to the inner lumen of the cryoballoon. Pressure curve characteristics are used to assess occlusion in conjunction with fluoroscopic or intracardiac echocardiography (ICE) guidance. PV occlusion is confirmed when loss of typical left atrial (LA) pressure waveform is observed with recordings of PA pressure characteristics (no A wave and rapid V wave upstroke). Complete pulmonary vein occlusion as assessed with this technique has been confirmed with concurrent contrast utilization during the initial testing of the technique and has been shown to be highly accurate and readily reproducible. We evaluated the efficacy of this novel technique in 35 patients. A total of 128 veins were assessed for occlusion with the cryoballoon utilizing the pressure monitoring technique; occlusive pressure was demonstrated in 113 veins with resultant successful pulmonary vein isolation in 111 veins (98.2%). Occlusion was confirmed with subsequent contrast injection during the initial ten procedures, after which contrast utilization was rapidly reduced or eliminated given the highly accurate identification of occlusive pressure waveform with limited initial training. Verification of PV occlusive pressure during CBA is a novel approach to assessing effective PV occlusion and it accurately predicts electrical isolation. Utilization of this method results in significant decrease in fluoroscopy time and volume of contrast.
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Affiliation(s)
- Ioanna Kosmidou
- Department of Cardiac Electrophysiology, Piedmont Heart Institute, USA.
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TRAULLÉ SARAH, MIYAZAKI SHINSUKE, MOUQUET VINCENT, KUBALA MACIEJ, HERMIDA JEANSYLVAIN. The Anatomic Impact of Sequential, Additional, Ostial Radiofrequency Ablation Following Pulmonary Vein Cryo-Isolation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1420-7. [DOI: 10.1111/j.1540-8159.2012.03521.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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ANDRADE JASONG, DUBUC MARC, GUERRA PETERG, MACLE LAURENT, MONDÉSERT BLANDINE, RIVARD LÉNA, ROY DENIS, TALAJIC MARIO, THIBAULT BERNARD, KHAIRY PAUL. The Biophysics and Biomechanics of Cryoballoon Ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1162-8. [DOI: 10.1111/j.1540-8159.2012.03436.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Schmidt M, Dorwarth U, Straube F, Wankerl M, Krieg J, Leber AW, Ebersberger HU, Daccarett M, Huber A, Rummeny E, Hoffmann E. A novel double cryoballoon strategy in persistent atrial fibrillation: a pilot study. Clin Res Cardiol 2012; 101:777-85. [PMID: 22484346 DOI: 10.1007/s00392-012-0456-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 03/27/2012] [Indexed: 02/06/2023]
Abstract
AIMS Cryoballoon technology is a promising technique in paroxysmal atrial fibrillation (AF) ablation. However, success rates in patients with persistent AF have not been convincing. There is a trend toward performing more extensive procedures that are referred to as 'pulmonary vein isolation plus.' To combine pulmonary vein isolation (PVI) and antral substrate modification, we used both the 23-mm and 28-mm cryoballoon in a single approach in patients with persistent AF. METHODS AND RESULTS 33 consecutive patients (26 men, age 60 ± 10 years, LA size 44 ± 5 mm) with persistent AF were prospectively included. All patients underwent the "double balloon strategy:" at least two applications at each pulmonary vein (PV) using the smaller 23-mm balloon to isolate the PV at the ostial level plus at least one additional freeze by the 28-mm balloon at the wide PV antral level. 7-day Holter monitors were performed during follow-up at 1, 3, 6, 9, 12, 18 and 24 months post-ablation. 131 of 133 PVs were targeted and isolated (98.4 %). A mean of 14 ± 2 cryoballoon applications per patient or 3.5 ± 1.5 applications per vein were performed. After a single procedure and mean follow-up of 15 ± 3 months, 69.7 % of patients remained in sinus rhythm (3-month blanking period). There were no major complications. CONCLUSIONS In persistent AF, the "double balloon strategy;" combining the small and large cryoballoon allowed ostial PV isolation followed by antral cryoablation is feasible, safe and associated with a favorable outcome.
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Affiliation(s)
- Martin Schmidt
- Department of Cardiology, Klinikum München-Bogenhausen, Englschalkingerstr. 77, 81925 Munich, Germany.
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Schmidt M, Dorwarth U, Straube F, Wankerl M, Krieg J, Leber AW, Huber A, Hoffmann E. Cryoballoon in atrial fibrillation ablation. Herz 2012; 37:153-8. [PMID: 22382139 DOI: 10.1007/s00059-012-3592-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Encouraging results of ablation therapy in patients with paroxysmal atrial fibrillation (AF) have prompted changes in professional practice guidelines. The most recent European guidelines have suggested that ablation might be offered as first-line therapy in selected patients. Cryoballoon ablation is a promising technology in interventional AF therapy. Two different sizes of the cryoballoon are currently available: a smaller (23 mm) and a larger (28 mm) balloon relative to the ostial diameter of the pulmonary veins. New tools, the circular mapping catheter and the use of intracardiac echocardiography, provide important periprocedural information. A meta-analysis of previous studies revealed outcome data with an AF-free survival rate of 72.83% at the 1-year follow-up in paroxysmal AF patients undergoing cryoballoon ablation. The most frequent, but reversible complication is phrenic nerve palsy with reported incidences up to 10%. All efforts must be taken to overcome this limitation, since the overall major complication rate tends to be lower in cryoballoon compared to radiofrequency ablation. In persistent AF, reported results in cryoballoon ablation had a limited success rate below 50% after a single procedure. A double balloon approach using both cryoballoon sizes might overcome some of the limitations in persistent AF. Prospective data and randomized studies are required. This article outlines the current status of cryoballoon technology in AF ablation therapy.
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Affiliation(s)
- M Schmidt
- Department of Cardiology, Klinikum Bogenhausen, Englschalkingerstrasse 77, Munich, Germany.
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