Treatment of Tachyarrhythmias Using Cryothermal Energy

  • D. L. Lustgarten
  • D. Keane
  • J. Ruskin
Conference paper


There are several energy sources available for the ablation of abnormally conducting cardiac tissue, with radiofrequency currently in clinical use for the treatment of numerous cardiac arrhythmias. There is a great deal of interest in developing alternative energy sources that could allow the creation of longer lesions with less thrombogenicity than are currently possible using radiofrequency. Some modalities that are under investigation are laser and microwave, which, like radiofrequency, rely on hyperthermy to cause tissue destruction. Another alternative is cryoablation, in which tissue destruction is effected through application of freezing temperatures. As will be discussed below, the cryolesion is quite distinct from lesions created by burning, preserving the basic underlying tissue structure which results in lesions that are less thrombogenic and have greater tensile strength. There is extensive clinical experience in the use of cryothermy in the surgical treatment of tachyarrhythmias where it has proven to be a safe and effective means of ablating electrically abnormal cardiac tissue. With the recent advent of percutaneous cryocatheters, there is now wider potential for the application of cryothermy in a variety of clinical settings. The following discussion contrasts potential advantages of using cryothermy versus modalities relying on hyperthermy and reviews the literature of the use of cryothermy in the surgical management of clinically important arrhythmias.


Atrial Fibrillation Ventricular Tachycardia None None Accessory Pathway Ventricular Tachy 
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  1. 1.
    Tsvetkov T, Tsonev L, Meranzov N et al (1985) Functional changes in mitochondrial properties as a result of their membrane cryodestruction. II. Influence of freezing and thawing on Atp complex activity of intact liver mitochondria. Cryobiology 22(2):111–118PubMedCrossRefGoogle Scholar
  2. 2.
    Petrenko A (1992) A mechanism of latent cryoinjury and reparation of mitochondria. Cryobiology 29(1):144–152PubMedCrossRefGoogle Scholar
  3. 3.
    Whittaker DK (1984) Mechanisms of tissue destruction following cryosurgery. Ann R Coll Surg Engl 66(5):313–318PubMedGoogle Scholar
  4. 4.
    Gill W, Fraser J, Carter DC (1988) Repeated freeze-thaw cycles in cryosurgery. Nature 219(5152):410–413CrossRefGoogle Scholar
  5. 5.
    Mazur M (1965) Causes of injury in frozen and thawed cells. Fed Proc 24:5175–5182Google Scholar
  6. 6.
    Mazur P (1970) Cryobiology: the freezing of biological systems. Science 168(934):939–949PubMedCrossRefGoogle Scholar
  7. 7.
    McGrath JJ (1993) Low temperature injury processes. In: Roemer RB (ed) Advances in bioheat and mass transfer: microscale analysis of thermal injury processes, instrumentation, modeling, and clinical applications. ASME Odyssey, New Hampshaire, 268:125–132Google Scholar
  8. 8.
    Stewart GJ, Preketes A, Horton M et al (1995) Hepatic cryotherapy: double-freeze cycles achieve greater hepatocellular injury in man. Cryobiology 32(3):215–219PubMedCrossRefGoogle Scholar
  9. 9.
    Gage AA, Guest K, Montes M et al (1985) Effect of varying freezing and thawing rates in experimental cryosurgery. Cryobiology 22(2):175–182PubMedCrossRefGoogle Scholar
  10. 10.
    Markovitz LJ, Frame LH, Josephson ME et al (1988) Cardiac cryolesions factors affecting their size and a means of monitoring their formation. Ann of Thorac Surg 46(5):531–535CrossRefGoogle Scholar
  11. 11.
    Ghalili K, Roth JA, Kwan SK et al (1992) Comparison of left ventricular cryolesions created by liquid nitrogen and nitrous oxide. J Am Coll Cardiol 20(6):1425–1429PubMedCrossRefGoogle Scholar
  12. 12.
    Fujino H, Thompson RP, Germroth PG et al (1993) Histologic study of chronic catheter cryoablation of atrioventricular conduction in swine. Am Heart J 125(6):1632–1637PubMedCrossRefGoogle Scholar
  13. 13.
    Harrison L, Gallagher JJ, Kasell J et al (1977) Cryosurgical ablation of the A-V node-His bundle: a new method for producing A-V block. Circulation 55(3):463–470PubMedCrossRefGoogle Scholar
  14. 14.
    Gillette PC, Swindle MM, Thompson RP et al (1991) Transvenous cryoablation of the bundle of His. Pacing Clin Electrophysiol 14(4 Pt 1):504–510PubMedCrossRefGoogle Scholar
  15. 15.
    Ohkawa S, Hackel DB, Mikat EM et al (1982) Anatomic effects of cryoablation of the atrioventricular conduction system. Circulation 65(6):1155–1162PubMedCrossRefGoogle Scholar
  16. 16.
    Holman WL, Ikeshita M, Douglas JM Jr et al (1983) Ventricular cryosurgery: short-term effects on intramural electrophysiology. Ann Thorac Surg 35(4):386–393PubMedCrossRefGoogle Scholar
  17. 17.
    Jensen JA, Kosek JC, Hunt TK et al (1987) Cardiac cryolesions as an experimental model of myocardial wound healing. Ann Surg 206(6):798–803PubMedCrossRefGoogle Scholar
  18. 18.
    Klein GJ, Harrison L, Ideker RF et al (1979) Reaction of the myocardium to cryosurgery: electrophysiology and arrhythmogenic potential. Circulation 59(2):364–372PubMedCrossRefGoogle Scholar
  19. 19.
    Hunt GB, Chard RB, Johnson DC et al (1989) Comparison of early and late dimensions and arrhythmogenicity of cryolesions in the normothermic canine heart. J Thorac Cardiovasc Surg 97(2):313–318PubMedGoogle Scholar
  20. 20.
    Gallagher JD, Del Rossi AJ, Fernandez J et al (1985) Cryothermal mapping of recurrent ventricular tachycardia in man. Circulation 71(4):732–739PubMedCrossRefGoogle Scholar
  21. 21.
    Gessman L, Agarwal J, Endo T et al (1983) Localization and mechanism of ventricular tachycardia by ice mapping 1 week after the onset of myocardial infarction in dogs. Circulation 68(3):657–666PubMedCrossRefGoogle Scholar
  22. 22.
    Wallace A, Mignone R (1966) Physiologic evidence concerning the reentry hypothesis of ectopic beats. Am Heart J 72:60–70PubMedCrossRefGoogle Scholar
  23. 23.
    Cole JS, Wills RE, Winterscheid LC et al (1970) The Wolff-Parkinson-White syndrome: problems in evaluation and surgical. Circulation 42(1):111–121PubMedCrossRefGoogle Scholar
  24. 24.
    Slama R, Blondeau P, Aigueperse J et al (1967) Surgical creation of an auriculoventri-cal block and implantation of a. Arch Mal Coeur Vaisse 60(3):406–422Google Scholar
  25. 25.
    Garcia R, Arciniegas E (1973) Recurrent atrial flutter. Treatment with a surgically induced atrioventricular block and ventricular pacing. Arch Int Med 132(5):754–757CrossRefGoogle Scholar
  26. 26.
    Klein GJ, Sealy WC, Pritchett EL et al (1980) Cryosurgical ablation of the atrioventricular node-His bundle: long-term follow-up and properties of the junctional pacemaker. Circulation 61(1):8–15PubMedCrossRefGoogle Scholar
  27. 27.
    Bredikis J (1985) Cryosurgical ablation of atrioventricular junction without extracorporeal circulation. J Thorac Cardiovasc Surg 90(l):61–67PubMedGoogle Scholar
  28. 28.
    Bredikis JJ, Bredikis AJ (1990) Surgery of tachyarrhythmia: intracardiac closed heart cryoablation. Pacing Clin Electrophysiol 13(12 Pt 2):1980–1984PubMedCrossRefGoogle Scholar
  29. 29.
    Louagie YA, Guiraudon GM, Klein GJ et al (1991) Closed heart cryoablation of the His bundle using an anterior septal approach. Ann Thorac Surg 51(4):616–619PubMedCrossRefGoogle Scholar
  30. 30.
    Pritchett ELC, Anderson RW, Benditt DG et al (1979) Reentry within the atrioventricular node. Surgical cure with preservation of atrioventricular conduction. Circulation 60:440–446PubMedCrossRefGoogle Scholar
  31. 31.
    Holman WL, Ikeshita M, Lease JG et al (1986) Cryosurgical modification of retrograde atrioventricular conduction. Implications for the surgical treatment of atrioventricular nodal reentry tachycardia. J Thorac Cardiovasc Surg 91(6):826–834PubMedGoogle Scholar
  32. 32.
    Holman WL, Hackel DB, Lease JG et al (1988) Cryosurgical ablation of atrioventricular nodal reentry: histologic localization of the proximal common pathway. Circulation 77(6):1356–1362PubMedCrossRefGoogle Scholar
  33. 33.
    Cox J, Holman W, Cain W (1987) Cryosurgical treatment of atrioventricular node reentrant tachycardia. Circulation 76(6):1329–1336PubMedCrossRefGoogle Scholar
  34. 34.
    Wood DL, Hammill SC, Porter CB et al (1988) Cryosurgical modification of atrioventricular conduction for treatment of atrioventricular node reentrant tachycardia. Mayo Clin Proc 63(10):988–992PubMedCrossRefGoogle Scholar
  35. 35.
    Holman WL, Ikeshita M, Lease JG et al (1988) Cardiac cryosurgery: regional myocardial blood flow of ventricular cryolesions. J Surg Res 41(5):524–528CrossRefGoogle Scholar
  36. 36.
    Sealy WC, Hattler BG Jr., Blumenschein SD et al (1969) Surgical treatment of Wolff- Parkinson-White syndrome. Ann Thorac Surg 8(1):1–11PubMedCrossRefGoogle Scholar
  37. 37.
    Iwa T, Mitsui T, Misaki T et al (1986) Radical surgical cure of the WPW syndrome: the Kazawa experience. J Thorac Cardiovasc Surg 91(2):225–233PubMedGoogle Scholar
  38. 38.
    Gallagher JJ, Sealy WC, Anderson RW et al (1977) Cryosurgical ablation of accessory atrioventricular connections: a method for correction of the pre-excitation syndrome. Circulation 55(3):471–479PubMedCrossRefGoogle Scholar
  39. 39.
    Guiraudon GM, Klein GJ, Gulamhusein S et al (1984) Surgical repair of Wolff-Parkinson- White syndrome: a new closed-heart technique. Ann Thorac Surg 37(1):67–71PubMedCrossRefGoogle Scholar
  40. 40.
    Guiraudon GM, Klein GJ, Sharma AD et al (1986) Closed-heart technique for Wolff- Parkinson-White syndrome: further experience and potential limitations. Ann Thorac Surg 42(6):651–657PubMedCrossRefGoogle Scholar
  41. 41.
    Watanabe S, Koyanagi H, Endo M et al (1989) Cryosurgical ablation of accessory atrioventricular pathways without cardiopulmonary bypass: an epicardial approach for Wolff-Parkinson-White syndrome. Ann Thorac Surg 47(2):257–264PubMedCrossRefGoogle Scholar
  42. 42.
    Bredikis J, Bredikis A (1985) Cryosurgical ablation of left parietal wall accessory atrioventricular connections through the coronary sinus without the use of extracorporeal circulation. J Thorac Cardiovasc Surg 90(2):199–205PubMedGoogle Scholar
  43. 43.
    Lee AW, Crawford FA Jr, Gillette PC et al (1989) Cryoablation of septal pathways in patients with supraventricular tachyarrhythmias. Ann Thorac Surg 47(4):566–568PubMedCrossRefGoogle Scholar
  44. 44.
    Andress JD, Vander Salm TJ, Huang SK (1991) Bidirectional bundle branch reentry tachycardia associated with Ebstein’s anomaly: cured by extensive cryoablation of the right bundle branch. Pacing Clin Electrophysiol 14(11 Pt 1):1639–1647PubMedCrossRefGoogle Scholar
  45. 45.
    Cox JL, Gallagher JJ, Ungerleider RM (1982) Encircling endocardial ventriculotomy for refractory ischemic ventricular tachycardia. IV. Clinical indications surgical technique mechanism of action and results. J Thorac Cardiovasc Surg 83(6):865–872PubMedGoogle Scholar
  46. 46.
    Guiraudon GM, Guiraudon CM, McLellan DG et al (1989) Mitral valve function after cryoablation of the posterior papillary muscle in the dog. Ann Thorac Surg 47(6):872–876PubMedCrossRefGoogle Scholar
  47. 47.
    McLellan D, Guiraudon G, Guiraudon C et al (1990) Extensive cryoablation of the left ventricular apex does not impair cardiac function. PACE 134:497 (abstr)Google Scholar
  48. 48.
    Gallagher JJ, Anderson RW, Kasell J et al (1978) Cryoablation of drug-resistant ventricular tachycardia in a patient with a variant of scleroderma. Circulation 57(1):190– 197PubMedCrossRefGoogle Scholar
  49. 49.
    Camm J, Ward DE, Cory-Pearce R et al (1979) The successful cryosurgical treatment of paroxysmal ventricular tachycardia. Chest 75(5):621–624PubMedCrossRefGoogle Scholar
  50. 50.
    Cox J (1985) The status of surgery for cardiac arrhythmias. Circulation 71:413PubMedCrossRefGoogle Scholar
  51. 51.
    Miller J, Kienzle M, Harken A et al (1984) Subendocardial resection for ventricular tachycardia: predictors of surgical success. Circulation 70:624–631PubMedCrossRefGoogle Scholar
  52. 52.
    Caceres J, Werner P, Jazayeri M et al (1988) Efficacy of cryosurgery alone for refractory monomorphic sustained ventricular tachycardia due to inferior wall infarction. J Am Coll Cardiol 11(6):1254–1259PubMedCrossRefGoogle Scholar
  53. 53.
    Hargrove WCD, Miller JM, Vassallo JA et al (1988) Improved results in the operative management of ventricular tachycardia related to inferior wall infarction. Importance of the annular isthmus. J Thorac Cardiovasc Surg 92(4):726–732Google Scholar
  54. 54.
    El-Sherif N, Mehra R, Gough WB et al (1983) Reentrant ventricular arrhythmias in the late myocardial infarction period. Interruption of reentrant circuits by cryothermal techniques. Circulation 68(3):644–656PubMedCrossRefGoogle Scholar
  55. 55.
    Moe GK (1962) On the multiple wavelet hypothesis of atrial fibrillation. Arch Int Pharmacodyn Ther 140:183–188Google Scholar
  56. 56.
    Boineau JP, Schuessler RB, Mooney CR et al (1980) Natural and evoked atrial flutter due to circus movement in dogs. Am J Cardiol 45(6):1167–1181PubMedCrossRefGoogle Scholar
  57. 57.
    Allessie MA, Lammers WJEP, Bonke IM et al (1984) Intra-atrial reentry as a mechanism for atrial flutter induced by acetylcholine and rapid pacing in the dog. Circulation 70(1):123–135PubMedCrossRefGoogle Scholar
  58. 58.
    Cox JL, Sundt TM 3rd (1997) The surgical management of atrial fibrillation. Annu Rev Med 48(23):511–523PubMedCrossRefGoogle Scholar
  59. 59.
    Swartz J, Pellersels G, Silvers J et al (1994) A catheter-based curative approach to atrial fibrillation in humans. Circulation 90(4, Part 2):I–335Google Scholar
  60. 60.
    Haïssaguerre M, Jais P, Shah DC et al (1996) Right and left atrial radiofrequency catheter ablation of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 7(12):1132–1144PubMedCrossRefGoogle Scholar
  61. 61.
    Haïssaguerre M, Jaïs P, Shah D et al (1998) Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 339(10):659–666PubMedCrossRefGoogle Scholar
  62. 62.
    Mitchell MA, McRury ID, Haines DE (1998) Linear atrial ablations in a canine model of chronic atrial fibrillation. Circulation 97:1176–1185PubMedCrossRefGoogle Scholar
  63. 63.
    Thibault B, Villemaire C, Talajic M et al (1998) Catheter cryoablation is a more effective and potentially safer method to create atrial conduction block: comparison with radiofrequency ablation. PACE 21(4, Part II):944Google Scholar
  64. 64.
    Keane D, Zhou L, Ruskin J (1997) Catheter ablation for atrial fibrillation. Semin Intervent Cardiol 2:251–265Google Scholar
  65. 65.
    Keane D, Zhou L, Haughtaling C et al (1999) Percutaneous cryothermal catheter ablation for the creation of linear atrial lesions. Ir Med J (in press)Google Scholar
  66. 66.
    Camm J, Ward DE, Spurrell RA et al (1980) Cryothermal mapping and cryoablation in the treatment of refractory cardiac arrhythmias. Circulation 62(1):67–74PubMedCrossRefGoogle Scholar
  67. 67.
    Cox JL, Ferguson TB Jr, Lindsay BD et al (1990) Perinodal cryosurgery for atrioventricular node reentry tachycardia in 23 patients. J Thorac Cardiovasc Surg 99(3):440– 449; discussion 449-450PubMedGoogle Scholar
  68. 68.
    Rowland E, Robinson K, Edmondson S et al (1988) Cryoablation of the accessory pathway in Wolff-Parkinson-White syndrome: initial results and long term follow up. Br Heart J 59(4):453–457PubMedCrossRefGoogle Scholar
  69. 69.
    Plumb V, DC M, JK K et al (1985) Cryosurgery for ventricular tachycardia. J Am Coll Cardiol 5(2):409 (Abstr)Google Scholar
  70. 70.
    Krafchek J, Lawrie GM, Wyndham CR (1986) Cryoablation of arrhythmias from the interventricular septum: initial experience with a new biventricular approach. J Thorac Cardiovasc Surg 91(3):419–427PubMedGoogle Scholar
  71. 71.
    Krafchek J, Lawrie GM, Roberts R et al (1986) Surgical ablation of ventricular tachycardia: improved results with a map-directed regional approach. Circulation 73(6):1239–1247PubMedCrossRefGoogle Scholar
  72. 72.
    Ott DA, Garson A Jr, Cooley DA et al (1987) Cryoablative techniques in the treatment of cardiac tachyarrhythmias. Ann Thorac Surg 43(2):138–143PubMedCrossRefGoogle Scholar
  73. 73.
    Vermeulen FE, Hemel NM van, Guiraudon GM et al (1988) Cryosurgery for ventricular bigeminy using a transaortic closed ventricular approach. Eur Heart J 9(9):979– 990PubMedGoogle Scholar
  74. 74.
    Page PL, Cardinal R, Shenasa M et al (1989) Surgical treatment of ventricular tachycardia. Regional cryoablation guided by computerized epicardial and endocardial mapping. Circulation 80(3 Pt 1):I124–134PubMedGoogle Scholar
  75. 75.
    Caceres J, Akhtar M, Werner P et al (1989) Cryoablation of refractory sustained ventricular tachycardia due to coronary artery disease. Am J Cardiol 63(5):296–300PubMedCrossRefGoogle Scholar
  76. 76.
    Lawrie GM, Pacifìco A, Kaushik RR (1989) Transannular cryoablation of ventricular tachycardia. Surgical technique and results. J Thorac Cardiovasc Surg 98(6): 1030– 1035; discussion 1035-1036PubMedGoogle Scholar
  77. 77.
    Rokkas CK, Nitta T, Schuessler RB et al (1994) Human ventricular tachycardia: precise intraoperative localization with potential distribution mapping. Ann Thorac Surg 57(6):1628–1635PubMedCrossRefGoogle Scholar
  78. 78.
    Graffìgna A, Minzioni G, Ressia L et al (1994) Surgical ablation of ventricular tachycardia secondary to congenital ventricular septal aneurysm. Ann Thorac Surg 57(4):921–924PubMedCrossRefGoogle Scholar
  79. 79.
    Misaki T, Tsubota M, Watanabe G et al (1994) Surgical treatment of ventricular tachycardia after surgical repair of tetralogy of Fallot. Relation between intraoperative mapping and histological findings. Circulation 90(1):264–271PubMedCrossRefGoogle Scholar
  80. 80.
    Lee R, Mitchell JD, Garan H et al (1994) Operation for recurrent ventricular tachycardia. Predictors of shortand long-term efficacy. J Thorac Cardiovasc Surg 107(3):732–742PubMedGoogle Scholar
  81. 81.
    Gharagozloo F, Porter CJ, Tazelaar HD et al (1994) Multiple myocardial hamartomas causing ventricular tachycardia in young children: combined surgical modification and medical treatment. Mayo Clin Proc 69(3):262–267PubMedCrossRefGoogle Scholar
  82. 82.
    Guiraudon GM, Thakur RK, Klein GJ et al (1994) Encircling endocardial cryoablation for ventricular tachycardia after myocardial infarction: experience with 33 patients. Am Heart J 128(5):982–989PubMedCrossRefGoogle Scholar
  83. 83.
    Shumway SJ, Johnson EM, Svendsen CA et al (1997) Surgical management of ventricular tachycardia. Ann Thorac Surg 63(6):1589–1591PubMedCrossRefGoogle Scholar
  84. 84.
    Robbins IM, Colvin EV, Doyle TP et al (1998) Pulmonary vein stenosis after catheter ablation of atrial fibrillation. Circulation 98(17):1769–1775PubMedCrossRefGoogle Scholar
  85. 85.
    Lustgarten D, Keane D, Ruskin J (1999) Cryothermal ablation: mechanism of tissue injury and current experience in the treatment of tachyarrhythmias. Progr Cardiovasc Dis (in press)Google Scholar

Copyright information

© Springer-Verlag Italia 2000

Authors and Affiliations

  • D. L. Lustgarten
    • 1
  • D. Keane
    • 1
  • J. Ruskin
    • 1
  1. 1.Massachusetts General HospitalBostonUSA

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