RESUMEN
BACKGROUND: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. A blanking period (BP) of 3 months is used in clinical trials and practice. However, the optimal BP duration after PVI remains undefined. OBJECTIVE: The aim of this study was to objectively define, using continuous monitoring by an implantable loop recorder, the optimal BP duration after cryoballoon PVI. METHODS: We enrolled consecutive patients who had cryoballoon PVI and an implantable loop recorder. We determined the time of the last confirmed episode of AF within the blanking period. This was then correlated with AF recurrence in the first year after ablation. RESULTS: There were 210 patients (66 ± 9 years; 138 [66%] male; 116 [55%] paroxysmal AF; CHA2DS2-VASc score, 2.5 ± 1.6). We defined 4 distinct groups based on the last AF episode within the BP: no AF days 0-90 (n = 96 [46%]) and last AF 0-30 days (n = 46 [22%]), 31-60 days (n = 18 [9%]), and 61-90 days (n = 50 [24%]). After the 3-month BP, 101 (48%) patients had AF recurrence at 160 ± 86 days. Compared with patients with no AF in the BP, those with recurrent AF and AF burden >0% 30 days after ablation had a significantly greater AF recurrence during long-term follow-up (P = .001). CONCLUSION: Our data show that the approximately one-third of patients in whom AF occurs and who have a burden of >0% after the first month that follows PVI are at significantly higher risk of long-term recurrent AF. We therefore suggest that the blanking period be limited to a month after cryoballoon PVI.
Asunto(s)
Fibrilación Atrial , Criocirugía , Venas Pulmonares , Humanos , Venas Pulmonares/cirugía , Fibrilación Atrial/cirugía , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/diagnóstico , Masculino , Femenino , Criocirugía/métodos , Anciano , Estudios de Seguimiento , Recurrencia , Resultado del Tratamiento , Electrocardiografía Ambulatoria/métodos , Factores de Tiempo , Sistema de Conducción Cardíaco/fisiopatología , Sistema de Conducción Cardíaco/cirugía , Persona de Mediana Edad , Ablación por Catéter/métodos , Estudios Retrospectivos , Electrocardiografía/métodosRESUMEN
BACKGROUND: There is no consensus on the most effective radiofrequency ablation strategy for the initial or repeated treatment of persistent atrial tachyarrhythmia (ATa). OBJECTIVE: To describe success and complication rates after the creation of left atrial (LA) linear lesions for recurrent persistent ATa following an index cryoballoon pulmonary vein isolation (PVI), and to identify predictors of ATa recurrence. METHODS: During March 2013 to March 2020, we prospectively included all consecutive patients undergoing repeat procedures for the treatment of persistent ATa. Radiofrequency ablation consisting of the creation of linear lesions: a roofline, a mitral isthmus and/or septal line, and a cavotricuspid isthmus line. All patients were prospectively followed up for ATa recurrence. RESULTS: Overall, 133 patients underwent 170 procedures after initial cryoballoon PVI (n=715). At least one pulmonary vein reconnection was observed in 60 patients (45.1%), all of whom underwent successful re-disconnection. After all the procedures, >90% of patients had a lesion pattern consisting of a roofline, a mitral isthmus and/or septal line, and a cavotricuspid isthmus line. ATa was terminated in 41 patients (35%). There were three cases of tamponade (3/170 procedures, 1.8%). Ninety-two patients (69.2%) were in sinus rhythm after a median (interquartile range) of 36 (21-53) months since the index cryoballoon PVI. Diagnosis-to-ablation time and LA area were predictors of recurrence in multivariable analysis. CONCLUSION: The creation of linear lesions is a safe and effective treatment strategy for the recurrence of persistent ATa after cryoballoon PVI. Longer diagnosis-to-ablation time and larger LA area were predictive of ATa recurrence.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Criocirugía , Venas Pulmonares , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/etiología , Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Criocirugía/efectos adversos , Criocirugía/métodos , Humanos , Venas Pulmonares/diagnóstico por imagen , Venas Pulmonares/cirugía , Recurrencia , Taquicardia/etiología , Taquicardia/cirugía , Resultado del TratamientoRESUMEN
Immobilization of patients during electrophysiological procedures, to avoid complications by patients' unexpected bodily motion, is achieved by moderate to deep conscious sedation using benzodiazepines and propofol for sedation and opioids for analgesia. Our aim was to compare respiratory and hemodynamic safety endpoints of cryoballoon pulmonary vein isolation (PVI) and electroanatomical mapping (EAM) procedures. Included patients underwent either cryoballoon PVI or EAM procedures. Sedation monitoring included non-invasive blood pressure measurements, transcutaneous oxygen saturation (tSpO2) and transcutaneous carbon-dioxide (tpCO2) measurements. We enrolled 125 consecutive patients, 67 patients underwent cryoballoon atrial fibrillation ablation and 58 patients had an EAM and radiofrequency ablation procedure. Mean procedure duration of EAM procedures was significantly longer (p < 0.001) and propofol doses as well as morphine equivalent doses of administered opioids were significantly higher in EAM patients compared to cryoballoon patients (p < 0.001). Cryoballoon patients display higher tpCO2 levels compared to EAM patients at 30 min (cryoballoon: 51.1 ± 7.0 mmHg vs. EAM: 48.6 ± 6.2 mmHg, p = 0.009) and at 60 min (cryoballoon: 51.4 ± 7.3 mmHg vs. EAM: 48.9 ± 6.6 mmHg, p = 0.07) procedure duration. Mean arterial pressure was significantly higher after 60 min (cryoballoon: 84.7 ± 16.7 mmHg vs. EAM: 76.7 ± 13.3 mmHg, p = 0.017) in cryoballoon PVI compared to EAM procedures. Regarding respiratory and hemodynamic safety endpoints, no significant difference was detected regarding hypercapnia, hypoxia and episodes of hypotension. Despite longer procedure duration and deeper sedation requirement, conscious sedation in EAM procedures appears to be as safe as conscious sedation in cryoballoon ablation procedures regarding hemodynamic and respiratory safety endpoints.
Asunto(s)
Fibrilación Atrial/cirugía , Mapeo del Potencial de Superficie Corporal/métodos , Sedación Consciente/métodos , Criocirugía/métodos , Monitoreo Fisiológico/métodos , Venas Pulmonares/cirugía , Anciano , Fibrilación Atrial/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Estudios Prospectivos , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: Long-term outcomes in terms of thromboembolic events (TEs) are poorly described after cryoballoon pulmonary vein isolation (cryo-PVI) for atrial fibrillation (AF). We evaluated the long-term incidence and predictive factors of TE after cryo-PVI. METHODS: All consecutive patients who underwent cryo-PVI for paroxysmal or persistent AF between November 2012 and October 2017 were included. They were prospectively followed for at least 12 months in the ablation center and then by their cardiologist. Data on all ischemic events (stroke, transient ischemic attack (TIA), systemic embolism) were collected. RESULTS: In total, 450 patients (78% men, median age 61 years) were included. The mean CHA2DS2-VASc score was 1.6 ± 1.3 and 26 patients (6%) had a history of stroke/TIA before the procedure. OAT was discontinued for 75 patients (17%) after the procedure, among whom 50 (67%) had no indication for long-term anticoagulation. Six patients experienced an ischemic event, all considered as a TE: three strokes, two TIAs, and one acute lower-limb ischemia. The mean follow up was 30 months. Thus, the incidence of TE was 0.53%/year. Three of the six patients who experienced a TE had no recurrence of atrial arrhythmia documented before, at the time, or after the event. All patients who experienced a TE had a class I or class IIa indication for long-term anticoagulation. After multivariate analysis, the CHA2DS2-VASc Score (p = .0005) was a predictor of TEs. CONCLUSION: The long-term incidence of TEs after cryo-PVI was 0.53%/year. The CHA2DS2-VASc Score was the only independent predictor of TEs.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Tromboembolia , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Fibrilación Atrial/cirugía , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Venas Pulmonares/cirugía , Medición de Riesgo , Factores de Riesgo , Tromboembolia/diagnóstico , Tromboembolia/epidemiología , Tromboembolia/etiologíaRESUMEN
AIM: The aim of the study was to investigate the role of anatomical characteristics of the pulmonary veins (PVs) determining cooling kinetics during second-generation cryoballoon ablation (CbA). METHODS AND RESULTS: we enrolled all consecutive patients who underwent CbA for symptomatic atrial fibrillation in our center from January 2019 to March 2019. All patients had complete computed tomography scans of the heart before the ablation. Anatomical characteristics were tested for prediction of a nadir temperature (NT) ≤ -48°C. Significant differences were noted among PV max diameter (20.8 ± 2.8 vs 18.5 ± 2.5 mm; P < .001); PV minimum diameter (15.2 ± 3.0 vs 13.0 ± 3.1 mm; P < .001); PV area (268.1 ± 71.9 vs 206.2 ± 58.7 mm2 ; P < .001); PV ovality (1.4 ± 0.3 vs 1.5 ± 0.3; P = .005); and PV trunk length (27.4 ± 7.4 vs 21.3 ± 6.5 mm; P < .001). A scoring system was created by assigning one point each ranging from 0 (best anatomical combination) to 5. In the group with a score of 0, 94.0% of the CbA could reach a NT ≤ -48°C whereas with a score of 5, only 29.0% (P < .001). Left superior pulmonary vein with short trunk length and acute angle of PV branch was significantly associated with warmer NT (11.8% satisfactory CbA; P = .003). Regarding right inferior pulmonary vein, trunk length (P = .004), maximum diameter (P = .044), and transverse angle (P = .008) were independently associated with good NT. CONCLUSION: Anatomical PV features are associated with cooling kinetics and an anatomical score could predict lower NT during second-generation CbA. Specific characteristics were identified for inferior PV. Although heart imaging is not mandatory prior CbA, it can be a useful tool to predict cooling kinetics.
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Fibrilación Atrial/cirugía , Frío , Criocirugía , Venas Pulmonares/cirugía , Anciano , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/fisiopatología , Frío/efectos adversos , Angiografía por Tomografía Computarizada , Criocirugía/efectos adversos , Femenino , Humanos , Cinética , Masculino , Persona de Mediana Edad , Flebografía , Venas Pulmonares/diagnóstico por imagen , Venas Pulmonares/fisiopatología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Few reports exist regarding the details of ice formation on second-generation cryoballoon (CB) surface during pulmonary vein isolation (PVI). We propose a new parameter "temperature drop" in thawing phase for predicting sufficient ice formation and CB-PVI outcome. METHODS: Consecutive 106 patients who underwent successful CB-PVI for atrial fibrillation (AF) were analyzed. We defined "temperature drop" as a temperature drop of more than 3 °C just after CB catheter bending. We compared the previously known parameters predicting durable PVI between PVs with or without temperature drop. Then, we compared the PVI outcome among three groups: group 1 with temperature drop in all PVs, group 2 with temperature drop in 1-3 PVs, and group 3 without temperature drop in any PV. RESULTS: Temperature drop was present in 206 out of 424 isolated PVs. In those, PV occlusion score was significantly higher (3.7 ± 0.5 vs. 3.5 ± 0.6, P <0.001), and thawing time was significantly longer (55 ± 20 vs. 46 ± 21 s, P < 0.001) in PVs with temperature drop than those without. With a mean follow up period of 376 ± 217 days, Kaplan-Meier survival analysis revealed that no patients in group 1 experienced AF recurrence, 14 out of 86 patients (16%) experienced AF recurrence in group 2, and 5 out of 10 (50%) patients experienced AF recurrence in group 3 (Log-Rank P = 0.003). CONCLUSION: The temperature drop in thawing phase might reflect the state of ice formation and can be used to predict clinical outcome after CB-PVI.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Criocirugía , Venas Pulmonares , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/cirugía , Humanos , Hielo , Venas Pulmonares/diagnóstico por imagen , Venas Pulmonares/cirugía , Recurrencia , Temperatura , Resultado del TratamientoRESUMEN
PURPOSE: Transmural thermal injury (TTI), such as esophageal erosion/ulcer and periesophageal nerve injury leading to gastric hypomotility, is not rare complications associated with pulmonary vein isolation (PVI). However, the mechanism and predicting factors of TTI have not yet been fully elucidated with second-generation cryoballoon (CB) PVI. METHODS: One hundred ten consecutive patients, who underwent CB PVI for atrial fibrillation and received esophagogastroduodenoscopy 2 days later, were investigated. The relationships between TTI and both clinical and anatomical parameters were examined. We measured the following parameters based on the computed tomography data: the angle of the left atrial (LA) posterior wall to the descending aorta (Ao) (LA-Ao angle); the branching angle of the left inferior pulmonary vein (LIPV) to the coronal plane (LIPV angle); and the minimum distance between the LA posterior wall and descending Ao enclosing the esophagus (LA-Ao distance). RESULTS: TTIs occurred in 19 patients (esophageal erosion in 2 and gastric hypomotility in 17). The patients with TTI were significantly older than those without TTI. In the anatomical parameters, the LIPV angle was larger and the LA-Ao distance was shorter in the TTI (+) group compared to the TTI (-) group. With the multivariate logistic regression analysis, the age (odds ratio [OR] 2.148, P = 0.022) and LA-Ao distance (OR 0.430, P = 0.013) were independent predictors of TTI. CONCLUSIONS: The occurrence of TTI in CB PVI was associated with aging, suggesting compromised periesophageal circulation, and the anatomical proximities between the LA and the descending Ao, which enclose the esophagus.
Asunto(s)
Fibrilación Atrial/cirugía , Quemaduras/etiología , Ablación por Catéter/efectos adversos , Criocirugía/efectos adversos , Imagenología Tridimensional , Venas Pulmonares/cirugía , Anciano , Fibrilación Atrial/diagnóstico por imagen , Quemaduras/epidemiología , Quemaduras/patología , Ablación por Catéter/métodos , Estudios de Cohortes , Criocirugía/métodos , Electrocardiografía/métodos , Femenino , Hospitales Universitarios , Humanos , Complicaciones Intraoperatorias/epidemiología , Complicaciones Intraoperatorias/fisiopatología , Japón , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Venas Pulmonares/diagnóstico por imagen , Estudios Retrospectivos , Tomografía Computarizada por Rayos X/métodosRESUMEN
AIMS: Real Time Recordings (RTR) of pulmonary vein (PV) activity provide important information in the setting of the 2nd generation Cryoballoon (CB-A), as a funcion of time to isolation. Visualization of RTR with the standard inner lumen mapping catheter (ILMC) 20mm Achieve (AC) is possible in roughly 50% of PVs. A novel 25mm-Achieve Advance (AC-A) has been developed with the aim of increasing the detection of RTR. The purpose of this study is to compare the AC-A with the AC, to feasibility and improvement of RTR. METHODS: We assigned 50 patients with paroxysmal or persistent atrial fibrillation to CB-A PVI, using the AC-A as ILMC. We compared this group with 50 patients, matched for age and left atrial volume, who previously underwent the CB-A PVI using the AC. RESULTS: RTR were more frequently observed with the AC-A than with the AC (74% vs 49%; p= 0.02). RTR in the left superior PVs was similar in both groups (74% vs 72%, p= 0.8). RTR with the AC-A were equally appreciated in left or right sided, superior or inferior PVs. No significant differences were found in terms of feasibility, procedure fluoroscopy and freezing times, nadir temperatures, and acute PVI. CONCLUSIONS: CB-A PVI with the AC-A is feasible and safe in all PVs. The AC-A has proven significantly superior in visualising RTR if compared to the AC, affording RTR in 74% of PVs.
RESUMEN
BACKGROUND: Vasovagal responses (VR) encountered during radiofrequency pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (PAF) suggest ablation of the atrial tissue subjacent to the ganglionic plexi (GP) and confer durability of PVI. OBJECTIVE: We hypothesized that VR during cryoballoon PVI (CB-PVI) in PAF can predict mid-term AF recurrence. METHODS: We enrolled 39 patients who underwent PVI using 2nd generation cryoballoon for PAF from November 2014 to July 2016. We evaluated the long term outcomes for those who had VR during index procedure. RESULTS: A total of 39 patients (76% male, mean age 57⯱â¯9â¯years) underwent CB-PVI for PAF and 66.67% (26/39) had VR. VR was frequently observed in the LSPV (100%), followed by RSPV (64%), LIPV (60%), and less frequently, RIPV (28%). Overall, the mean difference in the HR and SBP, and the relative differences in the HR and SBP were observed during CB-PVI in the LSPV (mean difference in HR, pâ¯<â¯0.001; mean difference in SBP, pâ¯<â¯0.001; relative difference in HR, pâ¯<â¯0.001); relative difference in SBP, pâ¯<â¯0.001). After PVI, 22/26 (84.62%) and 5/13 (38.46%) of patients in the VR and NVR group, respectively, maintained SR at 14⯱â¯6â¯months follow-up. The Kaplan-Meier analysis showed statistical difference in favor of patients with VR during CB-PVI (log rank pâ¯<â¯0.01) with a better mid-term outcome. CONCLUSION: In a small cohort of patients, VR during CB-PVI in PAF is a surrogate marker for ablation of atrial tissue subjacent to the GP and predicts a favorable mid-term outcome for AF recurrence.
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Fibrilación Atrial/diagnóstico por imagen , Ablación por Catéter/tendencias , Criocirugía/tendencias , Venas Pulmonares/diagnóstico por imagen , Síncope Vasovagal/diagnóstico por imagen , Anciano , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Estudios de Cohortes , Criocirugía/efectos adversos , Electrocardiografía/tendencias , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Venas Pulmonares/cirugía , Estudios Retrospectivos , Síncope Vasovagal/fisiopatología , Resultado del TratamientoAsunto(s)
Adrenomedulina/sangre , Fibrilación Atrial/sangre , Criocirugía/métodos , Sistema de Conducción Cardíaco/cirugía , Péptido Natriurético Encefálico/sangre , Fragmentos de Péptidos/sangre , Precursores de Proteínas/sangre , Venas Pulmonares/cirugía , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/cirugía , Biomarcadores/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , RecurrenciaRESUMEN
INTRODUCTION: Hemi-diaphragmatic paralysis is the most common complication associated with cryoballoon ablation for atrial fibrillation, yet the histopathology of phrenic nerve injury has not been well described. METHODS AND RESULTS: A preclinical randomized study was conducted to characterize the histopathology of phrenic nerve injury induced by cryoballoon ablation and assess the potential for electromyographic (EMG) monitoring to limit phrenic nerve damage. Thirty-two dogs underwent cryoballoon ablation of the right superior pulmonary vein with the objective of inducing phrenic nerve injury. Animals were randomized 1:1 to standard monitoring (i.e., interruption of ablation upon reduction in diaphragmatic motion) versus EMG guidance (i.e., cessation of ablation upon a 30% reduction in the diaphragmatic compound motor action potential [CMAP] amplitude). The acute procedural endpoint was achieved in all dogs. Phrenic nerve injury was characterized by Wallerian degeneration, with subperineural injury to large myelinated axons and evidence of axonal regeneration. The degree of phrenic nerve injury paralleled the reduction in CMAP amplitude (P = 0.007). Animals randomized to EMG guidance had a lower incidence of acute hemi-diaphragmatic paralysis (50% vs 100%; P = 0.001), persistent paralysis at 30 days (21% vs 75%; multivariate odds ratio 0.12, 95% confidence interval [0.02, 0.69], P = 0.017), and a lesser severity of histologic injury (P = 0.001). Mature pulmonary vein ablation lesion characteristics, including circumferentiality and transmurality, were similar in both groups. CONCLUSION: Phrenic nerve injury induced by cryoballoon ablation is axonal in nature and characterized by Wallerian degeneration, with potential for recovery. An EMG-guided approach is superior to standard monitoring in limiting phrenic nerve damage.