Persistence of an iatrogenic atrial septal defect after a second-generation cryoballoon ablation of atrial fibrillation
- 166 Downloads
Persistent iatrogenic atrial septal defects (iASDs) can be observed after intervention requiring a left atria (LA) access, including pulmonary vein isolation (PVI) of atrial fibrillation (AF). We investigated the incidence of iASDs post-second-generation cryoballoon ablation and the pre-procedural predictors. Eighty-three paroxysmal AF patients underwent PVI using second-generation cryoballoons. The LA was accessed with single 15-Fr steerable sheaths following a radiofrequency transseptal puncture, and the iASD was evaluated with transthoracic echocardiography (TTE), a median of 9.3 (7.1–13.3) months post-procedure. All patients underwent pre-procedural contrast-enhanced multi-detector computed tomography (CT) to evaluate the LA and PV anatomy. iASDs were detected by TTE in 7 (8.4%) patients, a median of 15.5 (6.8–17.3) months post-procedure. Patients with iASDs had significantly larger LA volumes and smaller atrial septal angles, defined as the angle between the atrial septum and sagittal line on the horizontal section at the height of the fossa ovalis, which could be the transseptal puncture site measured on CT, and more likely hypertension than those without. Multivariate analyses revealed that the atrial septal angle was the sole predictor of iASDs [odds ratio 0.764, 95% confidence interval (CI) 0.624–0.935, p = 0.009], and the optimal cut-off value was 57.5° (sensitivity 85.7%, specificity 88.2%, 95% CI 0.873–0.995, p < 0.0001). Patients with iASDs were asymptomatic and had no adverse clinical events during a 17.7 (14.4–25.8) month median follow-up. iASDs were still detectable in 8.4% of patients a median of 15.5 months after the second-generation CB ablation, and the atrial septal angle might aid in predicting persistent iASDs.
KeywordsIatrogenic atrial septal defect Cryoballoon ablation Atrial fibrillation Pulmonary vein isolation Transseptal puncture
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 author(s) 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, Heart Rhythm Society Task Force on Catheter and Surgical Ablation of Atrial Fibrillation (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. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm 9:632–696CrossRefPubMedPubMedCentralGoogle Scholar
- 3.Packer DL, Kowal RC, Wheelan KR, Irwin JM, Champagne J, Guerra PG, Dubuc M, Reddy V, Nelson L, Holcomb RG, Lehmann JW, Ruskin JN, Cryoablation Investigators STOPAF (2013) Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the North American Arctic Front (STOP AF) pivotal trial. J Am Coll Cardiol 61:1713–1723CrossRefPubMedGoogle Scholar
- 11.Sieira J, Chierchia GB, Di Giovanni G, Conte G, De Asmundis C, Sarkozy A, Droogmans S, Baltogiannis G, Saitoh Y, Ciconte G, Levinstein M, Brugada P (2014) One year incidence of iatrogenic atrial septal defect after cryoballoon ablation for atrial fibrillation. J Cardiovasc Electrophysiol 25:11–15CrossRefPubMedGoogle Scholar
- 16.Murakami T, Nakazawa G, Horinouchi H, Torii S, Ijichi T, Ohno Y, Amino M, Shinozaki N, Ogata N, Yoshimachi F, Yoshioka K, Ikari Y (2017) Transcatheter closure of atrial septal defect protects from pulmonary edema: septal occluder device gradually reduces LR shunt. Heart Vessels 32:101–104CrossRefPubMedGoogle Scholar
- 17.Rich ME, Tseng A, Lim HW, Wang PJ, Su WW (2015) Reduction of iatrogenic atrial septal defects with an anterior and inferior transseptal puncture site when operating the cryoballoon ablation catheter. J Vis Exp 100:e52811Google Scholar
- 18.Matoshvili Z, Bastani H, Bourke T, Braunschweig F, Drca N, Gudmundsson K, Insulander P, Jemtrén A, Kennebäck G, Saluveer O, Schwieler J, Tapanainen J, Wredlert C, Jensen-Urstad M (2017) Safety of fluoroscopy-guided transseptal approach for ablation of left-sided arrhythmias. Europace 19:2023–2026CrossRefPubMedGoogle Scholar