scholarly journals Characteristics of anatomical difficulty for cryoballoon ablation: insights from CT

Open Heart ◽  
2022 ◽  
Vol 9 (1) ◽  
pp. e001724
Author(s):  
Takahiro Hayashi ◽  
Masato Murakami ◽  
Shigeru Saito ◽  
Kiyotaka Iwasaki
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrium ◽  
Phrenic Nerve ◽  
Cochrane Library ◽  
Cryoballoon Ablation ◽  
Systematic Analysis ◽  
Acute Success ◽  
Poor Outcomes ◽  
The Right ◽  
Af Recurrence

BackgroundThe limited availability of balloon sizes for cryoballoon leads to anatomical limitations for pulmonary vein (PV) isolation. We conducted a comprehensive systematic analysis on procedural success rate, atrial fibrillation (AF) recurrence rate and complications of cryoballoon ablation in association with the anatomy of the left atrium and PV based on preprocedural CT to gain insights into proper treatments of patients with AF using cryoballoon.MethodA systematic search of literature databases, including PubMed, Web of Science and Cochrane Library, from the inception of each database through February 2021 was conducted. Search keywords included ‘atrial fibrillation’, ‘cryoballoon ablation’ and ‘anatomy’.ResultsOverall, 243 articles were identified. After screening, 16 articles comprising 1396 patients were included (3, 5 and 8 for acute success, AF recurrence and complications, respectively). Regarding acute success and AF recurrences, thinner width of the left lateral ridge, higher PV ovality, PV ostium-bifurcation distance, shorter distance from the non-coronary cusp to inferior PVs, shallower angle of right PVs against the atrial septum and larger right superior PV (RSPV) were associated with poor outcomes. Regarding complications, shorter distance between the RSPV ostium and the right phrenic nerve, larger RSPV-left atrium angle, larger RSPV area and smaller right carina width were associated with incidences of phrenic nerve injury.ConclusionThis study elucidated several key anatomical features of PVs possibly affecting acute success, AF recurrence and complications in patients with AF using cryoballoon ablation. CT analysis has helped to describe benefits and anatomical limitations for cryoballoon ablation.

scholarly journals Cryoballoon ablation of the left atrial posterior wall reduces recurrence of persistent atrial fibrillation in patients with non-paroxysmal atrial fibrillation

2021 ◽  
Author(s):  
Takatoshi Shigeta ◽  
Yasuteru Yamauchi ◽  
Yuichiro Sagawa ◽  
Atsuhito Oda ◽  
Shinichi Tachibana ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Paroxysmal Atrial Fibrillation ◽  
Left Atrial ◽  
Conduction Block ◽  
Persistent Atrial Fibrillation ◽  
Posterior Wall ◽  
Cryoballoon Ablation ◽  
Acute Success ◽  
Af Recurrence

Introduction: Detailed clinical outcomes of cryoballoon ablation of the left atrial (LA) posterior wall (LAPW) in patients with non-paroxysmal atrial fibrillation (AF) have not been fully examined. Methods: We analyzed the outcomes of 191 patients with non-paroxysmal AF, of whom 135 underwent cryoballoon ablation of the LAPW including the LA roof in addition to pulmonary vein isolation with a cryoballoon. Results: Complete conduction block at the LA roof was obtained in 97.0% (131/135) of patients and LAPW was isolated in 85.2% (115/135) of patients. Over 372 days (range, 182–450 days) of follow-up, atrial arrhythmia recurrence was observed in 55 (40.7%) patients, and atrial tachycardia (AT) recurrence accounted for 25.5% of cases. The prevalence of LA roof cryoballoon ablation tended to be higher in patients without recurrence than those with (74.3% vs. 61.8%, respectively; p=0.11), especially those with persistent AF recurrence (74.5% vs. 46.2%, p=0.01). Multivariate analysis revealed that cryoballoon ablation of the LA roof was a predictor of freedom from persistent AF recurrence and that it was not associated with AT recurrence. Durable LA roof lesions were confirmed in 18 (72.0%) of 25 patients who underwent redo ablation. Conclusion: Cryoballoon ablation of the LAPW leads to a sufficient acute success rate of complete conduction block and durable lesions of the LA roof without increasing the risk of AT recurrence. The prevalence of persistent AF recurrence decreases after additional cryoballoon ablation of the LAPW in patients with non-paroxysmal AF.

Final results from the EU focal impulse and rotor modulation (E-FIRM) registry

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
P Sommer ◽  
S Spitzer ◽  
J Brachmann ◽  
G Janssen ◽  
C Lenz ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrium ◽  
Right Atrium ◽  
Full Potential ◽  
Rf Ablation ◽  
Private Company ◽  
Single Procedure ◽  
History Of ◽  
The Right ◽  
Af Recurrence

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Abbott Background The exact pathophysiology of how pulmonary vein (PV) triggers initiate or maintain episodes of atrial fibrillation (AF) has been elusive. Catheter ablation at relatively circumscribed areas of rapidly spinning rotors or very rapid focal impulse formation can significantly affect AF. Targeted ablation of these sources using Focal Impulse and Rotor Modulation (FIRM™) shows promise. Purpose To assess the safety and effectiveness of FIRM-guided procedures for the treatment of any type of symptomatic atrial fibrillation (AF). Methods Two hundred and ninety-nine subjects were enrolled in the E-FIRM Registry at 9 clinical sites in Germany and the Netherlands. Subjects were eligible if they had reported incidence of at least 2 documented episodes of symptomatic AF during the preceding 3 months and had failed at least Class I or III anti-arrhythmia drug. Data was collected at enrollment/baseline, procedure, and at 3-, 6-, and 12-month follow-up visits. Results A majority (59.5%, 178/299) had a history of previous ablation, 81.1% (133/164) in the left side, with an average of 1.5 ± 0.8 [range 0, 5] prior ablations. The primary safety endpoint was defined as freedom from procedure related Serious Adverse Events (SAEs) through 7-days and at 12-months. At 7-days, freedom from procedure related SAEs was 94.8% (257/271). At 12-months, freedom from procedure related SAEs was 84.4% (184/218). There were no deaths. Acute effectiveness success, defined as the elimination of all identified rotors, occurred in 64.0% (165/258) of treated patients. All patients for which data was reported had at least 1 rotor identified. The most common regions to find rotors were the lateral wall of the right atrium, the anterior/septal wall of the left atrium, and the posterior inferior region of the left atrium. 75.2% (194/258) of patients had at least one rotor identified in the right atrium, and 84.1% (217/258) of patients had at least one rotor identified in the left atrium. Success was defined as two sequential endpoints: single procedure freedom from AF recurrence at 3-months and single procedure freedom from AF recurrence. At 12-months, success was achieved in 46.4% (13/28) Paroxysmal, 42.9% (87/203) Persistent, and 0% (0/9) Long Standing AF subjects. Conclusions: Since acute success was reported as being achieved in only ∼2/3 of the treated subjects, it is possible that the full potential benefit of the FIRM-guided ablation was hidden in this evaluation of the full cohort. Considering the previous ablation and disease history of subjects, a single-procedure success rate at 12-months over 40% was considered a positive result. Based on these results, FIRM-guided RF ablation in conjunction with conventional RF ablation practices is both a safe and effective treatment strategy for patients with symptomatic AF.

scholarly journals A simple method to detect phrenic nerve impairment during cryoballoon ablation of atrial fibrillation using aVF in the standard surface ECG

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
N Schaerli ◽  
S Knecht ◽  
F Spies ◽  
A Madaffari ◽  
S Osswald ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Nerve Injury ◽  
Phrenic Nerve ◽  
Nerve Palsy ◽  
Cryoballoon Ablation ◽  
Phrenic Nerve Palsy ◽  
Phrenic Nerve Injury ◽  
Surface Ecg ◽  
The Mean ◽  
The Right

Abstract Background Phrenic nerve palsy (PNP) is the most common complication in cryoballoon ablation of atrial fibrillation. Monitoring techniques such as compound motor action potential (CMAP) measurements using additional leads, or catheters positioned in the subdiaphragmatic hepatic vein or the esophagus have demonstrated to be effective to prevent PNP. Purpose This study investigates the safety and feasibility of a simple monitoring strategy using the lead aVF of the standard surface 12 lead ECG for CMAP monitoring to prevent PNP. Methods In 263 continuous patients undergoing cryoballoon ablation, a decapolar catheter was placed in the right subclavian vein to stimulate the phrenic nerve during ablation of the right sided pulmonary veins ([email protected] ms at 60 bpm). Capture was continuously monitored using the CMAP potential in the inferior aVF lead of the surface ECG and manually by palpation of the abdominal movement. The freeze was terminated early if the amplitude of the aVF signal decrease by >25% in three consecutive beats or if the diaphragmatic contraction decreased. Results Phrenic nerve injury documented by a reduction of the signal in aVF was observed in 13 of the 263 patients (5%) during freezes of the right superior pulmonary vein. Reduced diaphragmatic contraction detected by palpation of the abdomen was never observed without previous reduced amplitude in the surface aVF signal and was therefore never the trigger to stop a freeze. In patients with phrenic nerve injury, the mean initial amplitude was 1mV (SD ±0.3mV) and the mean minimal amplitude was 0.3mV (SD ±0.2mV). Mean time to recovery of the aVF amplitude was 160 seconds. Twelve patients (4.6%) showed complete recovery whereas one patient (0.4%) showed only partial recovery, as demonstrated in a sniff test at the end of the procedure. This patient showed no clinical signs of phrenic nerve palsy the following day, and full recovery was demonstrated in a sniff test 3 months later. Conclusion Monitoring of CMAP using the aVF signal from a standard 12-lead ECG during phrenic nerve stimulation to reduce the incidence of phrenic nerve palsy is safe and feasible. This technique is readily available during every standard ablation without placing additional electrodes and more sensitive than manual palpation. aVF signal before and during ablation Funding Acknowledgement Type of funding source: None

scholarly journals Anatomical correlation between left atrium pulmonary vein ablation targets of atrial fibrillation and adjacent bronchi and pulmonary arteries by MSCT

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Yan-Jing Wang ◽  
Huan Sun ◽  
Xiao-Fei Fan ◽  
Meng-Chao Zhang ◽  
Ping Yang ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrium ◽  
Pulmonary Vein ◽  
Pulmonary Arteries ◽  
Contact Points ◽  
Pulmonary Vein Ablation ◽  
Adjacent Structures ◽  
Anatomical Correlation ◽  
The Right

Abstract Background The ablation targets of atrial fibrillation (AF) are adjacent to bronchi and pulmonary arteries (PAs). We used computed tomography (CT) to evaluate the anatomical correlation between left atrium (LA)-pulmonary vein (PV) and adjacent structures. Methods Data were collected from 126 consecutive patients using coronary artery CT angiography. The LA roof was divided into three layers and nine points. The minimal spatial distances from the nine points and four PV orifices to the adjacent bronchi and PAs were measured. The distances from the PV orifices to the nearest contact points of the PVs, bronchi, and PAs were measured. Results The anterior points of the LA roof were farther to the bronchi than the middle or posterior points. The distances from the nine points to the PAs were shorter than those to the bronchi (5.19 ± 3.33 mm vs 8.62 ± 3.07 mm; P < .001). The bilateral superior PV orifices, especially the right superior PV orifices were closer to the PAs than the inferior PV orifices (left superior PV: 7.59 ± 4.14 mm; right superior PV: 4.43 ± 2.51 mm; left inferior PV: 24.74 ± 5.26 mm; right inferior PV: 22.33 ± 4.75 mm) (P < .001). Conclusions The right superior PV orifices were closer to the bronchi and PAs than other PV orifices. The ablation at the mid-posterior LA roof had a higher possibility to damage bronchi. CT is a feasible method to assess the anatomical adjacency in vivo, which might provide guidance for AF ablation.

scholarly journals Safety and efficacy of cryoballoon-ablation for atrial fibrillation performed at local hospitals: results of the german register on cryoballoon-ablation in local hospitals (REGIONAL)

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
J Michaelsen ◽  
U Parade ◽  
H Bauerle ◽  
K-D Winter ◽  
U Rauschenbach ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Phrenic Nerve ◽  
Nerve Palsy ◽  
Pulmonary Veins ◽  
Hospital Death ◽  
Cryoballoon Ablation ◽  
Complication Rates ◽  
Community Hospitals ◽  
Phrenic Nerve Palsy ◽  
Safety And Efficacy

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf REGIONAL Background Pulmonary vein isolation (PVI) using cryoballoon ablation (CBA) has become an established procedure for the treatment of symptomatic paroxysmal and persistent atrial fibrillation (AF). The safety and efficacy of PVI at community hospitals with low to moderate case numbers is unknown. Aim To determine safety and efficacy of PVI using CBA performed at community hospitals with limited annual case numbers. Methods 1004 PVI performed consecutively between 01/2019 and 09/2020 at 20 community hospitals (each &lt;100 PVI using CBA/year) for symptomatic paroxysmal AF (n = 563) or persistentAF (n= 441) were included in this registry. CBA was performed considering local standards. Procedural data, efficacy and complications were determined. Results Mean number of PVI using CBA/year was 59 ± 26. Mean procedure time was 90.1 ± 31.6 min and mean fluoroscopy time was 19.2 ± 11.4 min. Isolation of all pulmonary veins could be achieved in 97.9% of patients, early termination of CBA due to phrenic nerve palsy was the most frequent reason for incomplete isolation. There was no in-hospital death. 2 patients (0.2%) suffered a clinical stroke. Pericardial effusion occurred in 6 patients (0.6%), 2 of them (0.2%) required pericardial drainage. Vascular complications occurred in 24 patients (2.4%), in 2 of these patients (0.2%) vascular surgery was required. In 48 patients (4.8 %) phrenic nerve palsy was noticed which persisted up to hospital discharge in 6 patients (0.6%). Conclusions PVI for paroxysmal or persistent AF using CBA can be performed at community hospitals with high efficacy and low complication rates despite low to moderate annual procedure numbers.

Abstract 17710: Phrenic Nerve Injury Despite High-Output Pacing in Patients Undergoing Radiofrequency Catheter Ablation of Atrial Fibrillation

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Brett Izzo ◽  
Miki Yokokawa ◽  
Krit Jongnarangsin ◽  
Hamid Ghanbari ◽  
Rakesh Latchamsetty ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Phrenic Nerve ◽  
Maximum Output ◽  
Radiographic Findings ◽  
Long Duration ◽  
Mapping System ◽  
3D Mapping System ◽  
Rf Energy ◽  
The Right ◽  
High Output

Introduction: High-output pacing has been advocated as a strategy to avoid injury to the phrenic nerve (PN) during antral pulmonary vein (PV) isolation. We assessed the hypothesis that pacing does not prevent PN injury in patients undergoing radiofrequency (RF) ablation of atrial fibrillation (AF). Methods: The medical records of 198 consecutive patients (age=63±12 years, 129 men, ejection fraction=57±10%, LA=44±6mm, paroxysmal=49%) undergoing their first ablation procedure for AF were reviewed. All patients underwent antral PV isolation using a 3D mapping system (CARTO XP or CARTO 3) and a 3.5 mm irrigated-tip ablation catheter (maximum power, 25 W). Prior to RF energy delivery, high-output pacing (20 mA @ 10 ms, maximum output) was performed to asses for PN capture. Sites that afforded PN capture were avoided and RF energy was delivered at adjacent sites without PN capture. The 3-D maps were reviewed to identify the prevalence and sites of PN capture. Results: High-output pacing along the anterior right antrum resulted in PN capture in 35 patients (18%). The most common site with a positive response was the crux between the upper and lower PVs (60%), followed by the right superior PV (43%), and the right inferior PV (20%). Of the patients with PN capture, 49% had only one site of capture, 20% with two sites, and 31% had 3 or more sites. All PVs were isolated at the end of the procedure. Two patients (1%) developed PN injury (symptom onset on the day after the procedure), which was confirmed on radiography. In neither case was there evidence of PN capture during the procedure. Symptoms resolved in both patients within 3 months, with normalization of radiographic findings. Conclusions: High-output pacing along the anterior right PV antrum yields PN capture in roughly one-fifth of the patients undergoing PV isolation. Despite a negative response to pacing and alteration of the lesion set, PN injury may occur. The reason for this discordance is unknown, but may include the possibility that the capture threshold of the PN exceeds the maximum output of the stimulator, or that RF energy may injure the pericardiophrenic artery, which accompanies the PN. Avoiding high-power or long-duration lesions and high contact force in this region may minimize the risk of PN injury.

Abstract 4649: A Radiofrequency HOT Balloon Catheter for Isolating the Posterior Left Atrium Including All the Pulmonary Veins in the Treatment of Atrial Fibrillation: Feasibility and Safety of a New Approach

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Hiroshi Sohara ◽  
Shutaro Satake ◽  
Hiroshi Takeda ◽  
Hideki Ueno ◽  
Toshimichi Oda
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrium ◽  
Phrenic Nerve ◽  
Pulmonary Veins ◽  
Balloon Catheter ◽  
Holter Monitoring ◽  
Phrenic Nerve Palsy ◽  
Total Procedure Time ◽  
Successful Isolation

Atrial fibrillation (AF) is originated from mostly from pulmonary vein (PV) foci or non-PV foci in the posterior left atrium (PLA). The present study was designed to evaluate the usefulness of a radiofrequency HOT balloon catheter (RBC) for isolation of the PLA including all PVs en masse in the patients with AF. In a total of 96 patients (75 men and 21 women; mean age 64±8 years old) with drug-resistant paroxysmal (n=63) and persistent AF(n=33), PLA including all PVs were ablated and isolated using RBC. Dragging the balloon, contiguous lesions at the roof between the superior PVs were first created, then each antrum of all PVs were ablated, and finally, contiguous lesions at the PLA between the both inferior PVs were made, while we performed monitoring esophagus temperature and phrenic nerve pacing. Electro-anatomical bipolar voltage amplitude mapping (CARTO) of the LA-PVs was performed to determine the extent of this electrical isolation after all procedure. Successful isolation of the PLA including all PVs was achieved in all of 96 cases with elimination of all the PLA and PV potentials. The mean total procedure time 133 ± 31 minutes including 32±9 minutes fluoroscopy time. Recurrences of AF were diagnosed by Holter monitoring, mobile electrocardiogram. After first session, eighty- seven (59 paroxysmal, 28 persistent) of 96 patients were free from AF without anti-arrhythmic drugs and the remaining patients could maintain sinus rhythm with anti-arrhythmic drugs except two cases with LA flutter during 11.0±4.1 months follow-up. No major complications such as cerebral embolism, PV stenosis, or phrenic nerve palsy, and LA-esophageal fistula were observed. Complete isolation of the PLA including all PVs using a RBC, is useful for the treatment of both paroxysmal and persistent AF without severe complication.

scholarly journals Modulation of SERCA in Patients with Persistent Atrial Fibrillation Treated by Epicardial Thoracoscopic Ablation: The CAMAF Study

2020 ◽  
Vol 9 (2) ◽  
pp. 544 ◽  
Author(s):  
Celestino Sardu ◽  
Gaetano Santulli ◽  
Germano Guerra ◽  
Maria Consiglia Trotta ◽  
Matteo Santamaria ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrium ◽  
Persistent Atrial Fibrillation ◽  
Epicardial Ablation ◽  
Multicenter Observational Study ◽  
Endoplasmic Reticulum Calcium ◽  
One Year ◽  
Left Atrium Volume ◽  
First Time ◽  
Af Recurrence

Objectives: To evaluate atrial fibrillation (AF) recurrence and Sarcoplasmic Endoplasmic Reticulum Calcium ATPase (SERCA) levels in patients treated by epicardial thoracoscopic ablation for persistent AF. Background: Reduced levels of SERCA have been reported in the peripheral blood cells of patients with AF. We hypothesize that SERCA levels can predict the response to epicardial ablation. Methods: We designed a prospective, multicenter, observational study to recruit, from October 2014 to June 2016, patients with persistent AF receiving an epicardial thoracoscopic pulmonary vein isolation. Results: We enrolled 27 patients. Responders (n = 15) did not present AF recurrence after epicardial ablation at one-year follow-up; these patients displayed a marked remodeling of the left atrium, with a significant reduction of inflammatory cytokines, B type natriuretic peptide (BNP), and increased levels of SERCA compared to baseline and to nonresponders (p < 0.05). Furthermore, mean AF duration (Heart rate (HR) 1.235 (1.037–1.471), p < 0.05), Left atrium volume (LAV) (HR 1.755 (1.126–2.738), p < 0.05), BNP (HR 1.945 (1.895–1.999), p < 0.05), and SERCA (HR 1.763 (1.167–2.663), p < 0.05) were predictive of AF recurrence. Conclusions: Our data indicate for the first time that baseline values of SERCA in patients with persistent AF might be predictive of failure to epicardial ablative approach. Intriguingly, epicardial ablation was associated with increased levels of SERCA in responders. Therefore, SERCA might be an innovative therapeutic target to improve the response to epicardial ablative treatments.

Sign in / Sign up

Export Citation Format

Share Document