Anatomical pitfalls during encircling cryoablation of the left atrium for atrial fibrillation therapy in the pig

  • Douglas L. Jones
  • Gerard M. Guiraudon
  • Allan C. Skanes
  • Colette M. Guiraudon


We previously published encircling endocardial cryo-isolation of the pulmonary vein (PV) region. This study documented mechanisms of isolation failure using CARTO® mapping. Cryo-isolation used a modified Surgifrost® introduced via a Universal Cardiac Introducer® on the left atrial appendage. Of five pigs, two had incomplete isolation and repeat mapping: Activation was over Bachmann’s bundle (BB) in one and the coronary sinus (CS) in the other. Repeat cryoablation failed to eliminate gaps. Histologically, the BB gap had nonlesioned sub-epicardial fibres and thick fat covering the cryolesioned BB: fat protecting the epicardium from cryoablation. The inferior gap had a large CS, and a thick myocardium bridging the isthmus: myocardial thickness and CS thermal sink preventing transmural cryolesions. CARTO® mapping localized gaps. Although the CS is known to cause failure, its protective mechanism is not well documented. The BB gap is novel. These findings have important clinical implications for isolation of the PV region.


Cryolesion Ablation Bachmann’s bundle Coronary sinus Atrial fibrillation Pulmonary vein 



Supported in part by the Canadian Institutes of Health Research. Surgifrost® cryoprobes were provided by CryoCath Technologies, St. Clair, QC. Carto® catheters were provided by Biosense-Webster, a Johnson & Johnson Company, Diamond Bar, CA.


  1. 1.
    Bauer, A., McDonald, A. D., & Donahue, J. K. (2004). Pathophysiological findings in a model of persistent atrial fibrillation and severe congestive heart failure. Cardiovascular Research, 61, 764–770.PubMedCrossRefGoogle Scholar
  2. 2.
    Lin, J. L., Lai, L. P., Lin, C. S., Du, C. C., Wu, T. J., Chen, S. P., et al. (2003). Electrophysiological mapping and histological examinations of the swine atrium with sustained (> or =24 h) atrial fibrillation: A suitable animal model for studying human atrial fibrillation. Cardiology, 99, 78–84.PubMedCrossRefGoogle Scholar
  3. 3.
    Becker, A. E. (2004). Left atrial isthmus: Anatomic aspects relevant for linear catheter ablation procedures in humans. Journal of Cardiovascular Electrophysiology, 15, 809–812.PubMedCrossRefGoogle Scholar
  4. 4.
    Lemery, R., Guiraudon, G., & Veinot, J. P. (2003). Anatomic description of Bachmann’s bundle and its relation to the atrial septum. American Journal of Cardiology, 91, 1482–1485.PubMedCrossRefGoogle Scholar
  5. 5.
    Garrido, M. J., Williams, M., & Argenziano, M. (2004). Minimally invasive surgery for atrial fibrillation: Toward a totally endoscopic, beating heart approach. Journal of Cardiac Surgery, 19, 216–220.PubMedCrossRefGoogle Scholar
  6. 6.
    Todd, D. M., Skanes, A. C., Guiraudon, G., Guiraudon, C., Krahn, A. D., Yee, R., et al. (2003). Role of the posterior left atrium and pulmonary veins in human lone atrial fibrillation: Electrophysiological and pathological data from patients undergoing atrial fibrillation surgery. Circulation, 108, 3108–3114.PubMedCrossRefGoogle Scholar
  7. 7.
    Guiraudon, G. M., Jones, D. L., Baindridge, D., & Peters, T. M. (2007). Mitral valve implantation using off-pump closed beating intracardiac surgery: A feasibility study. Interactive Cardiovascular Thoracic Surgery, 6, 603.CrossRefGoogle Scholar
  8. 8.
    Guiraudon, G. M., Jones, D. L., Skanes, A. C., Bainbridge, D., Guiraudon, C. M., Jensen, S., et al. (2005). En bloc exclusion of the pulmonary vein region in the pig using off pump, beating, intra-cardiac surgery: A pilot study of minimally-invasive surgery for atrial fibrillation. Annals of Thoracic Surgery, 80, 1417–1423.PubMedCrossRefGoogle Scholar
  9. 9.
    Arora, R. C., Waldmann, M., Hopkins, D. A., & Armour, J. A. (2003). Porcine intrinsic cardiac ganglia. Anatomical Record, 271A, 249–258.CrossRefGoogle Scholar
  10. 10.
    Klein, G. J., Guiraudon, G. M., Perkins, D. G., Jones, D. L., Yee, R., & Jarvis, E. (1984). Surgical correction of the Wolff–Parkinson–White syndrome in the closed heart using cryosurgery: A simplified approach. In L. S. Wheatley (Ed.) Cryoanalgesia for horses (pp. 119–125). Wheatley, Ontario: Wheatley Hall.Google Scholar
  11. 11.
    Guiraudon, G. M., Klein, G. J., Gulamhusein, S., Jones, D. L., Yee, R., Perkins, D. G., et al. (1984). Surgical correction of the Wolff–Parkinson–White syndrome: A new closed-heart technique. Annals of Thoracic Surgery, 37, 67–71.PubMedCrossRefGoogle Scholar
  12. 12.
    Jones, D. L., Skanes, A., Guiraudon, G. M., Guiraudon, C. M., & Santioanni, D. (2002). Atrial arrhythmias: Localization and role of cryosurgery. International Journal of Bioelectromagnetism, 2, 119–121.Google Scholar
  13. 13.
    Skanes, A. C., Jones, D. L., Teefy, P., Guiraudon, C., Yee, R., Krahn, A. D., et al. (2004). Safety and feasibility of cryothermal ablation within the mid- and distal coronary sinus. Journal of Cardiovascular Electrophysiology, 15, 1319–1323.PubMedCrossRefGoogle Scholar
  14. 14.
    Guiraudon, G. M. (1987). Cryoablation, a versatile tool in arrhythmia surgery. Annals of Thoracic Surgery, 43, 129–130.PubMedCrossRefGoogle Scholar
  15. 15.
    Dubuc, M., Talajic, M., Roy, D., Thibault, B., Leung, T. K., & Friedman, P. L. (1998). Feasibility of cardiac cryoablation using a transvenous steerable electrode catheter. Journal of Interventional Cardiac Electrophysiology, 2, 285–92.PubMedCrossRefGoogle Scholar
  16. 16.
    Skanes, A. C., Klein, G., Krahn, A., & Yee, R. (2004). Cryoablation: Potentials and pitfalls. Journal of Cardiovascular Electrophysiology, 15, S28–S34.PubMedCrossRefGoogle Scholar
  17. 17.
    Guiraudon, G. M. (1993). Surgical treatment of atrial fibrillation. Herz, 18, 51–59.PubMedGoogle Scholar
  18. 18.
    Di, B. L., Fahmy, T. S., Patel, D., Bai, R., Civello, K., Wazni, O. M., et al. (2007). Remote magnetic navigation: Human experience in pulmonary vein ablation. Journal of the American College of Cardiology, 50, 868–874.CrossRefGoogle Scholar
  19. 19.
    Cappato, R., Negroni, S., Pecora, D., Bentivegna, S., Lupo, P. P., Carolei, A., et al. (2003). Prospective assessment of late conduction recurrence across radiofrequency lesions producing electrical disconnection at the pulmonary vein ostium in patients with atrial fibrillation. Circulation, 108, 1599–1604.PubMedCrossRefGoogle Scholar
  20. 20.
    Defauw, J. J., Guiraudon, G. M., van Hemel, N. M., Vermeulen, F. E., Kingma, J. H., & de Bakker, J. M. (1992). Surgical therapy of paroxysmal atrial fibrillation with the “corridor” operation. Annals of Thoracic Surgery, 53, 564–70.PubMedCrossRefGoogle Scholar
  21. 21.
    Todd, D. M., Skanes, A. C., Guiraudon, G. M., Klein, G. J., Krahn, A. D., Yee, R., et al. (2002). The pathology of the left atrium in human lone atrial fibrillation. Circulation, 106, II370.Google Scholar
  22. 22.
    Guiraudon, G. M., Campbell, C. S., Jones, D. L., McLellan, D. G., & MacDonald, J. (1985). Combined SA and node-AV isolation: A surgical alternative to His bundle ablation in patients with atrial fibrillation. Clinical and Investigative Medicine, 8, 57.Google Scholar
  23. 23.
    Leitch, J. W., Klein, G., Yee, R., & Guiraudon, G. (1991). Sinus node-atrioventricular node isolation: Long-term results with the “corridor” operation for atrial fibrillation. Journal of the American College of Cardiology, 17, 970–975.PubMedCrossRefGoogle Scholar
  24. 24.
    Ott, P., Kirk, M. M., Koo, C., He, D. S., Bhattacharya, B., & Buxton, A. (2007). Coronary sinus and fossa ovalis ablation: Effect on interatrial conduction and atrial fibrillation. Journal of Cardiovascular Electrophysiology, 18, 310–317.PubMedCrossRefGoogle Scholar
  25. 25.
    van Hemel, N. M., Defauw, J. J., Kingma, J. H., Jaarsma, W., Vermeulen, F. E., de Bakker, J. M., et al. (1994). Long-term results of the corridor operation for atrial fibrillation. British Heart Journal, 71, 170–176.PubMedCrossRefGoogle Scholar
  26. 26.
    van Hemel, N. M., Defauw, J. J., Guiraudon, G. M., Kelder, J. C., Jessurun, E. R., & Ernst, J. M. (1997). Long-term follow-up of corridor operation for lone atrial fibrillation: Evidence for progression of disease? Journal of Cardiovascular Electrophysiology, 8, 967–973.PubMedCrossRefGoogle Scholar
  27. 27.
    Cox, J. L. (2004). Surgical treatment of atrial fibrillation: A review. Europace, 5(Suppl 1), S20–S29.PubMedCrossRefGoogle Scholar
  28. 28.
    Klein, G. J., Guiraudon, G. M., Sharma, A. D., & Jones, D. L. (1985). Controlled cryothermal injury to the AV node: Feasibility for AV nodal modification. PACE [PAB], 8, 630–638.Google Scholar
  29. 29.
    Klein, G. J., Sealy, W. C., Pritchett, E. L. C., Harrison, L., Hackel, D. B., Davis, D., et al. (1980). Cryosurgical ablation of the atrioventricular node-his bundle: Long-term follow-up and properties of the junctional pace-maker. Circulation, 61, 8–15.PubMedGoogle Scholar
  30. 30.
    Natale, A., Pisano, E., Shewchik, J., Bash, D., Fanelli, R., Potenza, D., et al. (2000). First human experience with pulmonary vein isolation using a through-the-balloon circumferential ultrasound ablation system for recurrent atrial fibrillation. Circulation, 102, 1879–1882.PubMedGoogle Scholar
  31. 31.
    Schmidt, B., Chun, K. R., Kuck, K. H., & Antz, M. (2007). Pulmonary vein isolation by high intensity focused ultrasound. Indian Pacing and Electrophysiology Journal, 7, 126–133.PubMedGoogle Scholar
  32. 32.
    Hong, K. N., Russo, M. J., Liberman, E. A., Trzebucki, A., Oz, M. C., Argenziano, M., et al. (2007). Effect of epicardial fat on ablation performance: A three-energy source comparison. Journal of Cardiac Surgery, 22, 1–4.CrossRefGoogle Scholar
  33. 33.
    Armour, J. A., & Hopkins, D. A. (1984). Anatomy of the extrinsic effernet autonomic nerves and ganglia innervating the mammialian heart. In W. C. Randall (Ed.) Nervous control of cardiovascular function (pp. 20–44). New York: Oxford University Press.Google Scholar
  34. 34.
    Armour, J. A. (2004). Cardiac neuronal hierarchy in health and disease. American Journal of Physiology. Regulatory, Integrative and Comparative Physiology, 287, R262–R271.PubMedGoogle Scholar
  35. 35.
    Sherlag, B. J., Tamanasi, E., Edwards, J., Geng, N. P. S., Lazzra, R., & Jackmann, W. M. (2005). Mapping the onset of atrial fibrillation arising from pulmonary vein and non-pulmonry vein sites in the dog heart. Heart Rhythm, 2, S218.CrossRefGoogle Scholar
  36. 36.
    Sherlag, B. J., Yamanashi, W. S., Patel, U., & Jackman, W. M. (2005). Stimulation of the “sino-atrial” fat pad converts focal pulmonary vein firing into atrial fibrillation in the dog heart. Circulation, 108, IV–85.Google Scholar
  37. 37.
    Cummings, J. E., Gill, I., Akhrass, R., Dery, M., Biblo, L. A., & Quan, K. J. (2004). Preservation of the anterior fat pad paradoxically decreases the incidence of postoperative atrial fibrillation in humans. Journal of the American College of Cardiology, 43, 994–1000.PubMedCrossRefGoogle Scholar
  38. 38.
    Nakagawa, H., Sherlag, B. J., Wu, A. W., Lockwood, D., Yokoyama, K., Herring, L., et al. (2005). Addition of selective ablation of autonomic ganglia to pulmonary vein antrum ablation for treatment of paroxysmal and persistent atrial fibrillation. Circulation, 110, III–543.Google Scholar
  39. 39.
    Po, S. S., Scherlag, B. J., Yamanashi, W. S., Edwards, J., Zhou, J., Wu, R., et al. (2006). Experimental model for paroxysmal atrial fibrillation arising at the pulmonary vein-atrial junctions. Heart Rhythm, 3, 201–208.PubMedCrossRefGoogle Scholar
  40. 40.
    Jones, D. L., Tuomi, J., Ramsay, D., Guiraudon, C. M., Armour, J. A., Cardinal, R., et al. (2007). Left atrial neuroablation for atrial fibrillation: A feasibility study. Canadian Journal of Cardiology, 23(Suppl. C), 225C.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Douglas L. Jones
    • 1
    • 2
    • 3
  • Gerard M. Guiraudon
    • 3
    • 4
  • Allan C. Skanes
    • 2
    • 3
  • Colette M. Guiraudon
    • 5
  1. 1.Department of Physiology and PharmacologyThe University of Western OntarioLondonCanada
  2. 2.Department of MedicineThe University of Western OntarioLondonCanada
  3. 3.Canadian Surgical Technologies and Advance Robotics, Lawson Health Research Institute, London Health Science CenterLondonCanada
  4. 4.Imaging Group, Robarts Research InstituteThe University of Western OntarioLondonCanada
  5. 5.Department of PathologyThe University of Western OntarioLondonCanada

Personalised recommendations