Additional cryoapplications at the pulmonary vein antrum using a 28-mm second-generation cryoballoon: a pilot study of extra-pulmonary vein ablation
- 247 Downloads
Isolation areas post-28-mm cryoballoon pulmonary vein isolation (CB-PVI) are smaller than post-radiofrequency PV antrum isolation at the left superior PV (LSPV) antrum and recurrent atrial fibrillation (AF) can originate from this area. This pilot study evaluated the impact of additional extra-PV CB applications at the LSPV antrum following conventional CB-PVI. Eighteen paroxysmal AF patients underwent CB-PVI with single 3-min freeze techniques. Following the CB-PVI, 2-min CB applications were added once or twice at the LSPV antrum. Before and after extra-PV ablation, left atrial (LA) 3-D electroanatomical maps were created. Seventy-two total PVs were successfully isolated with 4.2 ± 0.4 applications/patient with 28-mm CBs. The mean LA posterior wall (LAPW) and non-isolated LAPW areas were 14.9 ± 3.6 and 6.9 ± 2.8 cm2, respectively. After 1.6 ± 0.5 mean extra-PV applications, the upper non-isolated LAPW area significantly decreased from 3.3 ± 1.8 to 2.5 ± 1.8 cm2 (p < 0.001). The lowest esophageal temperatures during the extra-PV ablation were 27 °C. The total procedure and fluoroscopic times were 72.8 ± 13.1 and 15.2 ± 5.9 min, respectively. Silent gastric hypomotility was detected in 2/9 patients 1 day later, and mild PV stenosis was observed in 4/72 PVs 3 months later, but did not progress. At 12-month after single procedures, 16 (88.9%) patients were free from recurrent AF off antiarrhythmic drugs. A median of 8.0 [6.0–10.0] months later, PV reconnections were detected in 3/12 (25.0%) PVs. The non-isolated LAPW area was significantly larger in the chronic than acute phase (14.3 ± 5.2 cm2, p = 0.016). This pilot study suggested the potential feasibility of additional LSPV antral cryoapplications following a conventional CB-PVI. The strategy warrants further study in more patients.
KeywordsCryoballoon Pulmonary vein isolation Atrial fibrillation Catheter ablation
We would like to thank Mr. John Martin for his help in the preparation of the manuscript.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no competing interests.
- 2.Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, DiMarco J, Edgerton J, Ellenbogen K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y, Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P, Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nakagawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E, Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D (2012) 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Heart Rhythm 9:632–696CrossRefPubMedPubMedCentralGoogle Scholar
- 3.Liu X, Dong J, Mavrakis HE, Hu F, Long D, Fang D, Yu R, Tang R, Hao P, Lu C, He X, Liu X, Vardas PE, Ma C (2006) Achievement of pulmonary vein isolation in patients undergoing circumferential pulmonary vein ablation: a randomized comparison between two different isolation approaches. J Cardiovasc Electrophysiol 17:1263–1270CrossRefPubMedGoogle Scholar
- 5.Kiuchi K, Kircher S, Watanabe N, Gaspar T, Rolf S, Arya A, Piorkowski C, Hindricks G, Sommer P (2012) Quantitative analysis of isolation area and rhythm outcome in patients with paroxysmal atrial fibrillation after circumferential pulmonary vein antrum isolation using the pace-and-ablate technique. Circ Arrhythm Electrophysiol 5:667–675CrossRefPubMedGoogle Scholar
- 6.Kojodjojo P, O’Neill MD, Lim PB, Malcolm-Lawes L, Whinnett ZI, Salukhe TV, Linton NW, Lefroy D, Mason A, Wright I, Peters NS, Kanagaratnam P, Davies DW (2010) Pulmonary venous isolation by antral ablation with a large cryoballoon for treatment of paroxysmal and persistent atrial fibrillation: medium-term outcomes and non-randomised comparison with pulmonary venous isolation by radiofrequency ablation. Heart 96:1379–1384CrossRefPubMedPubMedCentralGoogle Scholar
- 11.Reddy VY, Sediva L, Petru J, Skoda J, Chovanec M, Chitovova Z, Di Stefano P, Rubin E, Dukkipati S, Neuzil P (2015) Durability of pulmonary vein isolation with cryoballoon ablation: results from the sustained pv isolation with arctic front advance (SUPIR) study. J Cardiovasc Electrophysiol 26:493–500CrossRefPubMedGoogle Scholar
- 12.Heeger CH, Wissner E, Mathew S, Deiss S, Lemes C, Rillig A, Wohlmuth P, Reissmann B, Tilz RR, Ouyang F, Kuck KH, Metzner A (2015) Once isolated, always isolated? Incidence and characteristics of pulmonary vein reconduction after second-generation cryoballoon-based pulmonary vein isolation. Circ Arrhythm Electrophysiol 8:1088–1094CrossRefPubMedGoogle Scholar
- 14.Kenigsberg DN, Martin N, Lim HW, Kowalski M, Ellenbogen KA (2015) 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 12:283–290CrossRefPubMedGoogle Scholar
- 15.Miyazaki S, Taniguchi H, Hachiya H, Nakamura H, Takagi T, Iwasawa J, Hirao K, Iesaka Y (2016) 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 9:e003879CrossRefPubMedGoogle Scholar
- 16.Miyazaki S, Hachiya H, Nakamura H, Taniguchi H, Takagi T, Hirao K, Iesaka Y (2016) Pulmonary vein isolation using a second-generation cryoballoon in patients with paroxysmal atrial fibrillation: 1-year outcome using a single big-balloon 3-min freeze technique. J Cardiovasc Electrophysiol 27:1375–1380CrossRefPubMedGoogle Scholar
- 17.Sacher F, Monahan KH, Thomas SP, Davidson N, Adragao P, Sanders P, Hocini M, Takahashi Y, Rotter M, Rostock T, Hsu LF, Clémenty J, Haïssaguerre M, Ross DL, Packer DL, Jaïs P (2006) Phrenic nerve injury after atrial fibrillation catheter ablation: characterization and outcome in a multicenter study. J Am Coll Cardiol 47:2498–2503CrossRefPubMedGoogle Scholar
- 20.Ciconte G, Mugnai G, Sieira J, Velagić V, Saitoh Y, Irfan G, Hunuk B, Ströker E, Conte G, Di Giovanni G, Baltogiannis G, Wauters K, Brugada P, de Asmundis C, Chierchia GB (2015) On the quest for the best freeze: predictors of late pulmonary vein reconnections after second-generation cryoballoon ablation. Circ Arrhythm Electrophysiol 8:1359–1365PubMedGoogle Scholar
- 23.Miyazaki S, Nakamura H, Taniguchi H, Hachiya H, Takagi T, Igarashi M, Kajiyama T, Watanabe T, Niida T, Hirao K, Iesaka Y (2017) Gastric hypomotility after second-generation cryoballoon ablation-unrecognized silent nerve injury after cryoballoon ablation. Heart Rhythm 14:670–677CrossRefPubMedGoogle Scholar
- 24.Kuniss M, Greiß H, Pajitnev D, Akkaya E, Deubner N, Hain A, Bodammer L, Berkowitsch A, Chierchia GB, Hamm CW, Neumann T (2017) Cryoballoon ablation of persistent atrial fibrillation: feasibility and safety of left atrial roof ablation with generation of conduction block in addition to antral pulmonary vein isolation. Europace 19:1109–1115PubMedGoogle Scholar
- 27.Kato K, Ejima K, Fukushima N, Ishizawa M, Wakisaka O, Henmi R, Yoshida K, Nuki T, Arai K, Yashiro B, Manaka T, Ashihara K, Shoda M, Hagiwara N (2016) Catheter ablation of atrial fibrillation in patients with severely impaired left ventricular systolic function. Heart Vessels 31:584–592CrossRefPubMedGoogle Scholar