Comparison of Using Second-Generation Cryoballoon and Radiofrequency Catheter for Atrial Fibrillation Ablation in Patients With the Common Ostium of Inferior Pulmonary Veins

Aims: To compare the procedural outcomes of cryoballoon ablation (CBA) and radiofrequency ablation (RFA) in atrial fibrillation (AF) patients with the common ostium of inferior pulmonary veins (COIPV) and to explore the effect of COIPV on CBA performance through the assessment of anatomical factors.Methods: A total of 18 AF patients with COIPV were included. Pulmonary vein isolation (PVI) was performed with second-generation CBA or RFA. The anatomical characteristics of COIPV and procedural outcomes were collected.Results: The prevalence of COIPV was 0.82% in the enrolled population. PVI was achieved in all pulmonary veins (PVs) without any complications. The “tricircle” strategy was applied for RFA, and the segmental freeze strategy was performed for CBA. Compared with RFA, CBA had shorter procedural time (median: 53.0 vs. 78.0 min, p < 0.001) and longer fluoroscopy time (median: 13.5 vs. 6.0 min, p < 0.001). Higher ovality index of the ostium was seen in patients with ≥4 freezes in inferior PVs [IPVs; 0.95 (0.78–1.05) vs. 0.49 (0.21–0.83), p = 0.047]. During a median of 23.5 months of follow-up, the atrial arrhythmias-free survival after the procedure was comparable between CBA and RFA (p = 0.729).Conclusion: The second-generation CBA is an efficient and safe alternative for RFA in AF patients with COIPV. Anatomical characteristics of COIPV bring the challenge to the procedure performance of RFA and CBA.

Radiology of Anomalies of Pulmonary Veins

A study of 43 cases of suspected congenital diseases of heart was performed in Sahyadri Hospital, Pune, over a period of 5 to 6 years with dual source computed tomography (CT) in adolescents as well as children. Only the images of anomalies of pulmonary veins are presented.Compared with different radiological techniques, CT offers many advantages, as it can be undertaken even in neonates, yields more information than MR in a very little time, is better than 2D echo, when there is a small inter-costal window in some infants and is noninvasive. This study proved useful for further medical/surgical management.

Late arrhythmia recurrence after atrial fibrillation ablation: incidence, mechanisms and clinical implications

Background and objectives Catheter ablation of atrial fibrillation (AF) has become a well-established and widely used therapy, with pulmonary vein isolation (PVI) being the key modality of ablation. However, arrhythmia recurrences after PVI are common, with a relevant number of patients undergoing repeat ablation. Arrhythmia recurrence after PVI may vary regarding time point and mode of recurrence. While early arrhythmia recurrences of AF after PVI are mostly found to be the product of electrical reconnection of the pulmonary veins, the exact mechanisms of very late arrhythmia recurrence, occurring later than 12 months after successful PVI, remain unclear. This review provides an overview on the current evidence on time point and mechanisms of arrhythmia recurrence after PVI focussing on late arrhythmia recurrence. Recent findings The incidence of late arrhythmia recurrence after PVI can lie at a rate of up to 30% according to long-term follow-up studies. Mechanisms of recurrence include electrical reconnection of previously isolated pulmonary veins and development of atrial fibrosis. The use of cryoballoon ablation is likely to be more effective in reducing late arrhythmia recurrences compared to radiofrequency ablation. Novel scores such as the MB-LATER score or the APPLE score may become useful tools in predicting arrhythmia recurrence after PVI. Results and conclusion Late arrhythmia recurrence after PVI is common and leads to a relevant impairment of long-term success. Relevant data are currently limited and exact mechanisms of arrhythmia recurrence remain unclear. Further studies are needed to elucidate pathogenetic mechanisms of late arrhythmia recurrence after PVI in order to improve treatment strategies.

News from the Cold Chamber: Clinical Experiences of POLARx versus Arctic Front Advance for Single-Shot Pulmonary Vein Isolation

Cryoballoon (CB)-guided pulmonary vein isolation (PVI) represents a cornerstone in the treatment of atrial fibrillation (AF). Recently, a novel balloon-guided single shot device (POLARx, Boston Scientific) was designed. Our study aimed to compare the efficacy, safety and characteristics of the novel CB system with the established one (Arctic Front Advance (Pro), AFA, Medtronic). A total number of 596 patients undergoing CB-guided ablation for AF were included. 65 patients (65.0 ± 11.6, 31% female) undergoing PVI with the POLARx were compared to a cohort of 531 consecutive patients (63.0 ± 27.9, 25% female) treated with AFA. Acute PVI was achieved in all patients (n = 596, 100%). Total procedure duration (POLARx 113.3 ± 23.2 min, AFA 100.9 ± 21.3 min; p < 0.001) and fluoroscopy time (POLARx 10.5 ± 5.9 min, AFA 4.8 ± 3.6 min; p < 0.001) were significantly longer in the POLARx group. The POLARx balloon achieved significantly lower nadir temperatures (POLARx −57.7 ± 0.9 °C, AFA −45.1 ± 2.6 °C; p < 0.001) and a significantly higher percentage of pulmonary veins successfully isolated with the first freeze (p = 0.027 *). One major complication occurred in the POLARx (2%) and three (1%) in the AFA group. Both ablation systems are comparably safe and effective. AF ablation utilizing the POLARx system is associated with longer procedure and fluoroscopy times as well as lower nadir temperatures.

Modified autotransplantation technique for surgical resection of complex pericardial synovial sarcoma

Technical details for complex cardiac tumor resection are sparse. We describe the operative technique of modified autotransplantation for resection of a complex pericardial synovial sarcoma in a 63-year-old, Caucasian female. Surgical exposure demonstrated tumor origin at the superior cavoatrial junction and invasion of the aorta, main pulmonary artery, superior pulmonary veins, and left atrial roof. Full macroscopic surgical resection was achieved. The patient received adjuvant radiation for microscopic positive margins and remains alive and with no tumor progression at one year postoperatively. We conclude that modified autotransplantation is a challenging but effective surgical technique when performed with careful patient selection and availability of skilled, cardiothoracic surgeons at a cardiac center of excellence.

First-in-Human Experience and Acute Procedural Outcomes Using a Novel Pulsed Field Ablation System: The PULSED AF Pilot Trial

Background: Pulsed field ablation (PFA) is a novel form of ablation using electrical fields to ablate cardiac tissue. There are only limited data assessing the feasibility and safety of this type of ablation in humans. Methods: PULSED AF (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF; https://www.clinicaltrials.gov ; unique identifier: NCT04198701) is a nonrandomized, prospective, multicenter, global, premarket clinical study. The first-in-human pilot phase evaluated the feasibility and efficacy of pulmonary vein isolation using a novel PFA system delivering bipolar, biphasic electrical fields through a circular multielectrode array catheter (PulseSelect; Medtronic, Inc). Thirty-eight patients with paroxysmal or persistent atrial fibrillation were treated in 6 centers in Australia, Canada, the United States, and the Netherlands. The primary outcomes were ability to achieve acute pulmonary vein isolation intraprocedurally and safety at 30 days. Results: Acute electrical isolation was achieved in 100% of pulmonary veins (n=152) in the 38 patients. Skin-to-skin procedure time was 160±91 minutes, left atrial dwell time was 82±35 minutes, and fluoroscopy time was 28±9 minutes. No serious adverse events related to the PFA system occurred in the 30-day follow-up including phrenic nerve injury, esophageal injury, stroke, or death. Conclusions: In this first-in-human clinical study, 100% pulmonary vein isolation was achieved using only PFA with no PFA system–related serious adverse events.

Treatment of COVID-19 pneumonia and acute respiratory distress with ramatroban, a thromboxane A2 and prostaglandin D2 receptor antagonist: A 4-Patient Case Series Report

COVID-19 associated pneumonia and acute respiratory distress syndrome are accompanied by a massive and sustained increase in lung and systemic thromboxane (Tx) A2. TxA2 is a short-lived, potent vasoconstrictor of pulmonary veins > arteries, and thereby selectively increases pulmonary venous resistance, promoting an increase in pulmonary capillary pressure. TxA2 also increases vascular permeability which, in the lungs, exaggerates pressure-mediated transudation into the alveolar space, causing pulmonary edema and ARDS. Also relevant to COVID-19 pathophysiology, TxA2 contracts bronchial smooth muscle, triggers and amplifies platelet activation, mediates apoptosis of immature thymocytes, and promotes a procoagulant state, all of which are mediated by TxA2 receptor (TPr) activation. The stable TxA2 metabolite, 11-dehydro-TxB2, is elevated in direct proportion to COVID-19 severity. Though inactive at TPr, 11-dehydro-TxB2 activates PGD2 / DP2 receptors (DPr2) which promote a Th2 immune response that is atypical for viral infections and inhibits antiviral defense by suppressing interferon λ expression. Ramatroban is an orally bioavailable, potent, dual antagonist of TPr and DPr2 receptors. We report use of ramatroban (Baynas®, Bayer Yakuhin Ltd., Japan) in 4 COVID-19 outpatients, 22 to 87 years of age, with acute onset / worsening of respiratory distress and hypoxemia. All four patients experienced a decrease in respiratory distress and increase in SpO2, within hours of the first dose of ramatroban and, thereby, avoided hospitalization. By the 5th day all 4 patients had complete resolution of respiratory distress and hypoxemia. Ramatroban has an established safety profile, having been indicated in Japan for the treatment of allergic rhinitis for over 20 years. As an anti-vasospastic, broncho-relaxant, anti-thrombotic and immunomodulator, ramatroban addresses the fundamental host response mechanisms underlying respiratory and critical organ failure in COVID-19, and merits urgent clinical trials that might impact the ongoing pandemic.

Results of the early and mid-term postoperative period after correction of total anomalous pulmonary venous connection

<p><strong>Aim.</strong> To compare complications and outcomes in the postoperative period with two different methods for correcting total anomalous pulmonary venous connection.</p><p><strong>Methods. </strong>In this pilot, two-centre, simple, blind, prospective randomised study, the patients’ quality of life after correction of total anomalous pulmonary venous connection in infancy was evaluated using the sutureless (n = 20) and conventional repair methods (n = 20) in 40 patients. The overall mortality and complications in the mid-term were evaluated.</p><p><strong>Results.</strong> The average follow-up was 15 (13; 16) months. Mortality was noted only in the conventional repair group, amounting to 5 (25%) patients (p = 0.018). Severe obstruction of the pulmonary veins anastomosis was also noted only in the conventional repair group (n = 8, 40%; p = 0.0013). Infectious endocarditis was observed in one (6.6%) patient in the conventional repair group (p = 0.42). Arrhythmias were present in 4 (26.6%) patients in the conventional repair group (p = 0.02).</p><p><strong>Conclusion.</strong> The rates of obstruction of the pulmonary vein anastomosis, arrhythmias and death depend on the method of total anomalous pulmonary venous connection correction. The sutureless repair reduces the incidence of early and mid-term postoperative complications compared to conventional repair.</p><p>Received 16 March 2021. Revised 8 June 2021. Accepted 11 June 2021.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> The authors declare no conflict of interest.</p><p><strong>Contribution of the authors<br /> </strong>Conception and study design: Yu.N. Gorbatykh, A.V. Bogachev-Prokophiev, M.V. Plotnikov<br /> Data collection and analysis: M.V. Plotnikov, M.G. Galstyan, D.G. Tarasov<br /> Statistical analysis: M.V. Plotnikov<br /> Drafting the article: M.V. Plotnikov, Yu.N. Gorbatykh<br /> Critical revision of the article: I.A. Soynov<br /> Final approval of the version to be published: M.V. Plotnikov, Yu.N. Gorbatykh, A.N. Аrkhipov, M.G. Galstyan, A.V. Bogachev-Prokophiev, D.G. Tarasov, I.A. Soynov</p>

Epicardial Box Lesion Using Bipolar Biparietal Radiofrequency and Multimodality Scar Evaluation - a case series

Background Surgical epicardial AF ablation can be performed as a stand-alone (thoracoscopic) procedure or concomitant to other cardiac surgery. In hybrid AF ablation thoracoscopic surgical epicardial ablation is combined with a percutaneous endocardial ablation. The Medtronic Gemini-S clamp is a surgical tool that uses irrigated bipolar biparietal RF energy applied with two clamp lesions that overlap to create one epicardial box lesion including the posterior LA wall and the pulmonary veins. Case summary We describe three patients with therapy-refractory persistent AF and different stages of atrial remodelling in whom the Medtronic Cardioblate Gemini-S Irrigated RF Surgical Ablation System was used for hybrid AF ablation. Acute endocardial validation at the end of the hybrid ablation revealed a complete box lesion in all three cases. At 2-year follow-up, two out of three patients had recurrence of atrial arrhythmias. Invasive electro-anatomical mapping confirmed persistence of the box lesion, and the mechanism of arrhythmia recurrence in both patients was unrelated to posterior left atrium or the pulmonary veins. The third patient has been without arrhythmia symptoms since the ablation procedure. A 3D late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) illustrates the ablation scar non-invasively in two cases. Discussion Thoracoscopic biparietal RF AF ablation with the Medtronic Cardioblate Gemini-S Irrigated RF Surgical Ablation System results in permanent transmural scar formation, irrespective of the stage of atrial remodelling, as shown in this small population by means of multimodality scar evaluation.