scholarly journals Acute fluctuating neurological deficits after pulmonary vein isolation: unmasking a rare complication due to spontaneous spinal subdural bleeding: a case report

2019 ◽  
Vol 3 (3) ◽  
Author(s):  
Giacomo Maria Cioffi ◽  
François Regoli ◽  
Giulio Conte ◽  
Angelo Auricchio
Keyword(s):  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Lower Limb ◽  
Pulmonary Veins ◽  
Vascular Complications ◽  
Neurological Deficits ◽  
Bleeding Complications ◽  
Motor Deficits ◽  
Density Mapping ◽  
First Case

Abstract Background Pulmonary vein isolation (PVI) is becoming the therapy of choice for symptomatic paroxysmal drug-refractory atrial fibrillation (AF). The most frequently reported complications are vascular complications (1.4%). Bleeding complications of the central nervous system have rarely been described. We report a case of spontaneous spinal bleed after PVI. Case summary A 68-year-old woman with a 2-year history of highly symptomatic paroxysmal AF (EHRA 3) was referred for a PVI redo procedure. A high-density mapping showed pulmonary vein reconnection of all pulmonary veins successfully isolated by radiofrequency ablation. During the entire procedure, the patient had sinus rhythm with an ACT around 300 s. No intraprocedural and peri-procedural complications occurred. Four hours after haemostasis, the anticoagulation clotting time (ACT) was 110 s and rivaroxaban (20 mg) was reinitiated. In the following hours, the patient developed fluctuating neurological lower limb symptoms. A lumbar magnetic resonance imaging showed a subdural spinal haematic collection with an associated epidural component from L3 to S2 exerting compression over the dural sheath. A conservative treatment approach was adopted with progressive recovery of sensorial and motor deficits. After 5 months, the patient still presented residual lower limb motor deficits necessitating the support of a walking stick. Discussion We describe the first case of a spontaneous spinal bleeding following PVI. Given the gradual diffusion of PVI to treat AF in more clinically complex patients with a larger range of comorbidities, particular consideration should be given to seek predisposing bleeding factors in order to assess the risk for neurological complications.

scholarly journals Complications in pulmonary vein isolation in the Netherlands Heart Registration differ with sex and ablation technique

EP Europace ◽  
2020 ◽  
Author(s):  
Daniel Mol ◽  
Saskia Houterman ◽  
Jippe C Balt ◽  
Rohit E Bhagwandien ◽  
Yuri Blaauw ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
The Netherlands ◽  
Cardiac Tamponade ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Vascular Complications ◽  
Bleeding Complications ◽  
Invasive Treatment ◽  
Female Sex

Abstract Aims  Pulmonary vein isolation (PVI) has become a cornerstone of the invasive treatment of atrial fibrillation. Severe complications are reported in 1–3% of patients. This study aims to compare complications and follow-up outcome of PVI in patients with atrial fibrillation. Methods and results  The data were extracted from the Netherlands Heart Registration. Procedural and follow-up outcomes in patients treated with conventional radiofrequency (C-RF), multielectrode phased RF (Ph-RF), or cryoballoon (CB) ablation from 2012 to 2017 were compared. Subgroup analysis was performed to identify variables associated with complications and repeat ablations. In total, 13 823 patients (69% male) were included. The reported complication incidence was 3.6%. Patients treated with C-RF developed more cardiac tamponades (C-RF 0.8% vs. Ph-RF 0.3% vs. CB 0.3%, P ≤ 0.001) and vascular complications (C-RF 1.7% vs. Ph-RF 1.2% vs. CB 1.3%, P ≤ 0.001). Ph-RF was associated with fewer bleeding complications (C-RF: 1.0% vs. Ph-RF: 0.4% vs. CB: 0.7%, P = 0.020). Phrenic nerve palsy mainly occurred in patients treated with CB (C-RF: 0.1% vs. Ph-RF: 0.2% vs. CB: 1.5%, P ≤ 0.001). In total, 18.4% of patients were referred for repeat ablation within 1 year. Female sex, age, and CHA2DS2-VASc were independent risk factors for cardiac tamponade and bleeding complications, with an adjusted OR for female patients of 2.97 (95% CI 1.98–4.45) and 2.02 (95% CI 1.03–4.00) respectively. Conclusion  The reported complication rate during PVI was low. Patients treated with C-RF ablation were more likely to develop cardiac tamponades and vascular complications. Female sex was associated with more cardiac tamponade and bleeding complications.

Real-time local impedance monitoring to assess tissue lesion during pulmonary vein isolation: a new tool for AF ablation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Di Cori ◽  
L Segreti ◽  
G Zucchelli ◽  
S Viani ◽  
F Tarasco ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Contact Force ◽  
Vascular Complications ◽  
Lesion Formation ◽  
Tissue Impedance ◽  
Af Ablation ◽  
Group 2 ◽  
Group 1

Abstract Background Contact force catheter ablation is the gold standard for treatment of atrial fibrillation (AF). Local tissue impedance (LI) evaluation has been recently studied to evaluate lesion formation during radiofrequency ablation. Purpose Aim of the study was to assess the outcomes of an irrigated catether with LI alghorithm compared to contact force (CF)-sensing catheters in the treatment of symptomatic AF. Methods A prospective, single-center, nonrandomized study was conducted, to compare outcomes between CF-AF ablation (Group 1) and LI-AF ablation (Group 2). For Group 1 ablation was performed using the Carto 3© System with the SmartTouch SF catheter and, as ablation target, an ablation index value of 500 anterior and 400 posterior. For Group 2, ablation was performed using the Rhythmia™ System with novel ablation catheter with a dedicated algorithm (DirectSense) used to measure LI at the distal electrode of this catheter. An absolute impedance drop greater than 20Ω was used at each targeted. According to the Close Protocol, ablation included a point by point pulmonary vein isolation (PVI) with an Inter-lesion space ≤5 mm in both Groups. Procedural endpoint was PVI, with confirmed bidirectional block. Results A total of 116 patients were enrolled, 59 patients in Group 1 (CF) and 57 in Group 2 (LI), 65 (63%) with a paroxismal AF and 36 (37%) with a persistent AF. Baseline patients features were not different between groups (P=ns). LI-Group showed a comparable procedural time (180±89 vs 180±56, P=0.59) but with a longer fluoroscopy time (20±12 vs 13±9 min, P=0.002). Wide antral isolation was more often observed in CF-Group (95% vs 80%, P=0.022), while LI-Group 2 required frequently additional right or left carina ablation (28% vs 14%, P=0.013). The mean LI was 106±14Ω prior to ablation and 92.5±11Ω after ablation (mean LI drop of 13.5±8Ω) during a median RF time of 26 [19–34] sec for each ablation spot. No steam pops or complications during the procedures were reported. The acute procedural success was 100%, with all PVs successfully isolated in all study patients. Regarding safety, only minor vascular complications were observed (5%), without differences between groups (p=0.97). During follow up, 9-month freedom from atrial fibrillation/atrial flutter/atrial tachycardia recurrence was 86% in Group 1 and 75% in Group 2 (P=0.2). Conclusions An LI-guided PV ablation strategy seems to be safe and effective, with acute and mid-term outcomes comparable to the current contact force strategy. LI monitoring could be a promising complementary parameter to evaluate not only wall contact but also lesion formation during power delivery. Procedural Outcomes Funding Acknowledgement Type of funding source: None

scholarly journals 16-22: Quantification of the ablation zone after wide area circumferential pulmonary vein isolation applying a new high-density mapping system

EP Europace ◽  
2016 ◽  
Vol 18 (suppl_1) ◽  
pp. i6-i6
Author(s):  
Francesco Santoro ◽  
Ardan Saguner ◽  
Christine Lemes ◽  
Christian Sohns ◽  
Shibu Mathew ◽  
...  
Keyword(s):  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
High Density ◽  
Wide Area ◽  
Ablation Zone ◽  
Density Mapping ◽  
Mapping System ◽  
Circumferential Pulmonary Vein Isolation

P1415Wide antral circumferential pulmonary vein isolation ablation using a novel balloon cryoablation catheter

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
A P Martin ◽  
M Fowler ◽  
N Lever
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrium ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Paroxysmal Atrial Fibrillation ◽  
Left Atrial ◽  
Pulmonary Veins ◽  
Posterior Wall ◽  
The Novel ◽  
Median Treatment

Abstract Background Pulmonary vein isolation using cryotherapy is an established treatment for the management of patients with paroxysmal atrial fibrillation. Ablation using the commercially available balloon cryocatheter has been shown to create wide antral pulmonary vein isolation. A novel balloon cryocatheter (BCC) has been designed to maintain uniform pressure and size during ablation, potentially improving contact with the antral anatomy. The extent of ablation created using the novel BCC has not previously been established. Purpose To determine the anatomical extent of pulmonary vein isolation using electroanatomical mapping when performing catheter ablation for paroxysmal atrial fibrillation using the novel BCC. Methods Nine consecutive patients underwent pre-procedure computed tomography angiography of the left atrium to quantify the chamber dimensions. An electroanatomical map was created using the cryoablation system mapping catheter and a high definition mapping system. A bipolar voltage map was obtained following ablation to determine the extent of pulmonary vein isolation ablation. A volumetric technique was used to quantify the extent of vein and posterior wall electrical isolation in addition to traditional techniques for proving entrance and exit block. Results All patients had paroxysmal atrial fibrillation, mean age 56 years, 7 (78%) male. Electrical isolation was achieved for 100% of the pulmonary veins; mean total procedure time was 109 min (+/- 26 SD), and fluoroscopy time 14.9 min (+/- 2.4 SD). The median treatment applications per vein was one (range one - four), and median treatment duration 180 sec (range 180 -240). Left atrial volume 32 mL/m2 (+/- 7 SD), and mean left atrial posterior wall area 22 cm2 (+/- 4 SD). Data was available for quantitative assessment of the extent of ablation for eight patients. No lesions (0 of 32) were ostial in nature. The antral surface area of ablation was not statistically different between the left and right sided pulmonary veins (p 0.63), which were 5.9 (1.6 SD) and 5.4 (2.1 SD) cm2 respectively. In total 50% of the posterior left atrial wall was ablated.  Conclusion Pulmonary vein isolation using a novel BCC provides a wide and antral lesion set. There is significant debulking of the posterior wall of the left atrium. Abstract Figure.

Initial Experience with Robotic Epicardial Off-Pump Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation

2006 ◽  
Vol 1 (5) ◽  
pp. 247-250
Author(s):  
Filip Casselman ◽  
Ihsan Bakir ◽  
Pedro Brugada ◽  
Peter Geelen ◽  
Francis Wellens ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Paroxysmal Atrial Fibrillation ◽  
Pulmonary Veins ◽  
Median Sternotomy ◽  
Transverse Sinus ◽  
Right Atrial ◽  
Off Pump

Objective To evaluate the feasibility and results of isolated endoscopic pulmonary vein isolation for paroxysmal atrial fibrillation using robotics. Methods Between November 2004 and December 2005, 13 patients (38.5% female) underwent robotic pulmonary vein isolation at our institution. Mean age was 46.8 ± 8.4 years and mean preoperative duration of atrial fibrillation was 52.7 ±31.5 months. Indication for surgery was symptomatic drug-refractory paroxysmal atrial fibrillation or recurrence after percutaneous treatment (n = 3). Mean preoperative left atrial dimension was 38.5 ± 6.9 mm. The surgical procedure was performed off-pump as an isolated right chest approach. All procedures were performed using the Flex 10 microwave ablator (Guidant, Indianapolis, IN), which was positioned from the right side through the transverse sinus and around the 4 pulmonary veins. Postoperative drug regimen included sotalol and Coumadin. Mean follow-up was 8.5 ± 3.4 months. Results The procedure was successful in 11 patients. One patient needed conversion to median sternotomy for right pulmonary artery bleeding and a second patient had severe transverse sinus adhesions requiring conversion to a bilateral video-assisted small thoracotomy approach. No other morbidity occurred. Mean procedure time in successful cases was 2.7 ± 0.8 hours (range 1.7 to 4 hours). Permanent sinus rhythm was successfully restored in 10 of 13 patients (76.9% beyond 6 months). Nonsuccessful patients had markedly reduced symptoms and frequency of events. One patient required a left and another a right atrial flutter ablation during follow-up. Conclusions Robotic pulmonary vein isolation is a feasible procedure that has the potential to become a valid option in the treatment of paroxysmal atrial fibrillation.

scholarly journals Long-Standing Persistent Atrial Fibrillation Ablation: How Do You Perform? Left and Right Atrial Linear Ablation in Addition to Pulmonary Vein Isolation

2020 ◽  
Vol 33 (2) ◽  
pp. 106-114
Author(s):  
Michele Brunelli ◽  
Mark Adrian Sammut
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Low Voltage ◽  
Superior Vena ◽  
Pulmonary Veins ◽  
Vena Cava ◽  
Persistent Atrial Fibrillation ◽  
Right Atrial ◽  
Linear Ablation

Catheter ablation of long-standing persistent atrial fibrillation is not yet clearly defined with respect to endpoints, and different ablative strategies are offered to patients. Presented here is an approach aiming at biatrial debulking in the form of extensive linear ablation, specifically targeting areas of low-voltage complex fractionated electrograms, in addition to pulmonary vein isolation. Its main advantage is that it is not dependent on operator/system variability, since the strategy of isolating the pulmonary veins, superior vena cava and left atrial posterior wall together with achievement of bidirectional block during linear ablation provides objective endpoints that can consistently be reproduced.

scholarly journals Prospective Randomized Clinical Trial of Wide Area Circumferential Pulmonary Vein Ablation versus Segmental Pulmonary Vein Ablation for Pulmonary Vein Isolation as a Treatment for Short-Duration Paroxysmal Atrial Fibrillation

2021 ◽  
Author(s):  
Sapan Bhuta ◽  
Gustaf Sverin ◽  
Hiro Kawata ◽  
Malek Bashti ◽  
Jessica Hunter ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Short Duration ◽  
Pulmonary Vein Isolation ◽  
Paroxysmal Atrial Fibrillation ◽  
Pulmonary Veins ◽  
Wide Area ◽  
Pulmonary Vein Ablation ◽  
Total Procedure Time

Background: Previous studies suggest that wide area circumferential pulmonary vein ablation (WACA) is more effective than segmental pulmonary vein ablation (SPVA) for pulmonary vein isolation (PVI) for treatment of atrial fibrillation. Whether this is true in patients (pts) with very short duration paroxysmal atrial fibrillation (PAF) is unknown. Objective: To compare WACA to SPVA in pts with PAF lasting <48 hours. Methods: One hundred pts with PAF <48 hours were randomized to either WACA vs SPVA (45 and 53 pts respectively, with 2 withdrawals), and followed up for 24 months with 14-day ECGs every 6 months. Results: Among 97 pts at an average of 22.1±4.8 months followup, 26 (57.8%) remained free of any atrial arrhythmias after WACA versus 29 (55.86%) after SPVA (p=0.64). Sixteen pts (35.6%) had recurrent PAF after WACA versus 20 pts (38.5%) after SPVA (p=0.79). Seven pts (15.6%) had atrial flutter after WACA versus 5 pts (9.64%) after SPVA (p=0.376) and 1 pt (2.2%) had atrial tachycardia after WACA vs 1 pt (1.9%) after SPVA (p=0.918). Total procedure time was lower for SPVA vs WACA (242.9 vs 271.1 minutes, p= 0.047), and fluoroscopy time similar for WACA vs SPVA (50.8 vs 53.4 minutes, p=0.555). Conclusions: As an initial ablation approach in pts with PAF <48 hours, SPVA was similarly effective to WACA with respect to arrhythmia recurrence, supporting the central role of the pulmonary veins for maintaining AF in these pts. Future therapies using alternative ablation energies may incorporate these insights to reduce risk to gastroesophageal structures.

scholarly journals Short tip–more function? Atrial fibrillation ablation using the novel third-generation cryoballoon in resected pulmonary vein

2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Shaojie Chen ◽  
Boris Schmidt ◽  
Stefano Bordignon ◽  
Fabrizio Bologna ◽  
K. R. Julian Chun
Keyword(s):  
Atrial Fibrillation ◽  
Real Time ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Pulmonary Veins ◽  
Cryoballoon Ablation ◽  
Third Generation ◽  
The Novel ◽  
Case Presentation ◽  
Pulmonary Surgery

Abstract Background Cryoballoon ablation is an established procedure for atrial fibrillation (AF). Patients who had previous pulmonary surgery undergoing pulmonary vein isolation (PVI) were seldom reported. Case presentation We describe an AF ablation using the novel short-tip third-generation cryoballoon in a patient with resected pulmonary vein. All pulmonary veins were successfully isolated without complication. The short-tip third-generation cryoballoon shows advantageous profile in PVI for AF patients with previous pulmonary surgery. Conclusions This report indicates that for AF patient who had previous resected PV surgery, the short-tip CB 3 provides an ideal device option for real-time PVI.

P984Residual gaps in the ablation line and requirement for carina ablation during contact force-guided radiofrequency pulmonary vein isolation: determinants and prognostic implications

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M J Mulder ◽  
M J B Kemme ◽  
M J W Gotte ◽  
H A Hauer ◽  
G J M Tahapary ◽  
...  
Keyword(s):  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Contact Force ◽  
Pulmonary Veins ◽  
Survival Analyses ◽  
Kaplan Meier ◽  
Significant Difference ◽  
Prognostic Implications ◽  
Ablation Line ◽  
Af Recurrence

Abstract Background Pulmonary vein isolation (PVI) is not always achieved after initial encircling of the pulmonary veins (PVs). Additional touch-up lesions are frequently required to close residual gaps, which may occur both in the initial ablation line and on the intervenous carina. Purpose We aimed to identify determinants and prognostic implications of residual gaps during index radiofrequency PVI. Methods Two hundred fourteen AF (atrial fibrillation) patients (57% paroxysmal, 61% male, mean age 62±9 years) undergoing contact force-guided PVI were studied. Residual gaps after initial encircling of the PVs were targeted for additional ablation and were classified as either gap ablation in the initial WACA (wide-area circumferential ablation) circle or carina ablation, depending on the site of earliest activation. After a waiting period of at least 30 minutes, persistence of PVI was tested through administration of 9–18 mg intravenous adenosine. Pre-procedural cardiac computed tomography imaging was used to assess left atrial and PV anatomy. Carina width was defined as the distance between ipsilateral superior and inferior PV ostia. Ablation procedures were analyzed to define the perimeter of the WACA circle. Results One hundred thirty-three patients (62%) required additional ablation lesions beyond the initial WACA circles to achieve complete PVI. Gap ablation was required in the left WACA circle in 34 patients (16%) and in the right WACA circle in 49 patients (23%). Left and right carina ablation were required in 50 (23%) and 83 (39%) patients, respectively. Multivariate analyses identified carina width and perimeter of the WACA circle as independent predictors of requirement for ipsilateral carina ablation, whereas paroxysmal AF and the perimeter of the WACA circle were associated with requirement of gap ablation in the initial WACA circle. Recurrence of atrial tachyarrhythmias was documented in 73 patients (34%) at 12 months follow-up. Kaplan–Meier survival analyses demonstrated a significantly higher rate of recurrence in patients with one or more residual gaps in the ablation line (43% vs. 30%, p=0.019, figure A), whereas no significant difference between patients with and without requirement of carina ablation was found (38% and 29%, respectively; p=0.111, figure B). Kaplan-Meier survival analyses Conclusion Residual gaps in the initial WACA circle were associated with increased AF recurrence rate after PVI, whereas residual gaps on the intervenous carina had no statistically significant impact on AF recurrence. Consequently, gaps occurring in the ablation line and gaps on the intervenous carina may represent different mechanisms and may have different prognostic implications.

Sign in / Sign up

Export Citation Format

Share Document