Abstract
BackgroundCryoballoon ablation (CBA) for pulmonary vein isolation (PVI) is a standard in atrial fibrillation (AF) ablation but might not be enough in complex atrial arrhythmias (AA). An open three-dimensional wide-band dielectric imaging system (3D-WBDIS) has been introduced to guide CBA.Material and MethodsPilot study evaluating feasibility and safety of 3D-WBDIS in combination with CBA and optional radiofrequency ablation (RFA) in patients with complex AA defined as (1) history of persistent AF, (2) additional atrial tachycardia/flutter, or (3) previous left atrial ablation.ResultsProspectively, seventeen patients, 68.9 ± 12.2 years of age, with complex AA were enrolled. In 70 pulmonary veins (PV), balloon positioning maneuvers (n = 129) were guided additionally by the occlusion tool (1.84/PV). Compared to angiography, its sensitivity and specificity was 94.5, and 85%, respectively. CBA-PVI was achieved in 100% of PVs including variants. In 68 maps, the median number of mapping points was 251.0 (interquartile range (IQR) 298.0) with a median map volume of 52.8 (IQR 83.9) mL. Following CBA, six additional arrhythmias (two right and two left atrial flutter, one left atrial appendage tachycardia, and one atrioventricular nodal reentry tachycardia) were identified and successfully ablated by means of RFA in five patients (29.4%). Left atrial and fluoroscopy times were 88 (IQR 40) and 20 (IQR 10) minutes, respectively. Dose area product was 1,100 (IQR 1252) cGyxcm2. Freedom from AA after 6 months follow-up time and 90 days blanking period was documented in 10/17 (59%) patients, and 8/17 (47%) without a blanking period. No major complication was observed.ConclusionThe combined use of CBA with optional RFA guided by a novel 3D-WBDIS is feasible and safe in patients suffering from complex AA. The occlusion tool shows high sensitivity and specificity for assessment of the balloon occlusion. Additional arrhythmias were successfully mapped and ablated. Short-term outcome is promising, and subsequent prospective, larger outcome studies are necessary to confirm our observations.
Highlights
The interventional treatment of atrial fibrillation (AF) has a strong level of recommendation in current guidelines as it shows superiority compared to anti-arrhythmic drug treatment, improves symptoms, and quality of life (1, 2)
The first step of our strategy consisted of a straightforward cryoballoon ablation (CBA) based pulmonary vein isolation (PVI) which was guided by using the occlusion tool software module provided by the new imaging system in addition to conventional pulmonary vein (PV) angiography
Sensitivity and specificity of the occlusion tool were similar in our study as compared to Cauti et al (94.5 and 85% vs. 91 and 71%), the negative predictive value (NPV) in our study was slightly lower in the present investigation (74 vs. 88.6%)
Summary
The interventional treatment of atrial fibrillation (AF) has a strong level of recommendation in current guidelines as it shows superiority compared to anti-arrhythmic drug treatment, improves symptoms, and quality of life (1, 2). Pulmonary vein isolation (PVI) by means of radiofrequency ablation (RFA) or cryoballoon ablation (CBA) is recommended with a class I indication. The use of additional ablation lesions beyond PVI (low voltage areas, lines, fragmented activity, ectopic foci, rotors, and others) may be considered but is not well-established (class IIb recommendation) (1, 2). Cryoballoon ablation (CBA) for pulmonary vein isolation (PVI) is a standard in atrial fibrillation (AF) ablation but might not be enough in complex atrial arrhythmias (AA). An open three-dimensional wide-band dielectric imaging system (3D-WBDIS) has been introduced to guide CBA
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