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Persistence of an iatrogenic atrial septal defect after a second-generation cryoballoon ablation of atrial fibrillation

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Abstract

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.

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Acknowledgements

We would like to thank Mr. John Martin for his help in the preparation of the manuscript.

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Authors and Affiliations

  1. Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, 4-1-1 Otsuno, Tsuchiura, Ibaraki, 300-0028, Japan

    Tomonori Watanabe, Shinsuke Miyazaki, Takatsugu Kajiyama, Sadamitsu Ichijo, Takamitsu Takagi, Miyako Igarashi, Hiroaki Nakamura, Hiroshi Taniguchi, Hitoshi Hachiya & Yoshito Iesaka

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  1. Tomonori Watanabe
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  2. Shinsuke Miyazaki
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  3. Takatsugu Kajiyama
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  4. Sadamitsu Ichijo
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  5. Takamitsu Takagi
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  6. Miyako Igarashi
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  10. Yoshito Iesaka
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Correspondence to Tomonori Watanabe.

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Fig.

 1. Panel A is a short axis image on TTE. Panel B is an image of the horizontal plane of the enhanced CT. The location of the iASD is evaluated by the ratio that was calculated with the distance from the basal atrial septum to the iASD (a) divided by the distance from the basal atrial septum to the aortic cusp (b). (JPEG 95 kb)

Fig.

 2. The atrial septal angle and direction of the transseptal puncture in patients without an iASD (panel A: The angle is 70 degree) and with an iASD (panel B: The angle is 55 degree) are shown. Please see the explanation in the Discussion section. (JPEG 107 kb)

Fig.

 3. The different angles of transseptal lines (blue arrows) against the atrial septum are shown. Please see the explanation in the Discussion section. (JPEG 163 kb)

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Watanabe, T., Miyazaki, S., Kajiyama, T. et al. Persistence of an iatrogenic atrial septal defect after a second-generation cryoballoon ablation of atrial fibrillation. Heart Vessels 33, 1060–1067 (2018). https://doi.org/10.1007/s00380-018-1147-z

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  • DOI: https://doi.org/10.1007/s00380-018-1147-z

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