Pouches, pectinate & prominent peaks: pitfalls during cavotricuspid isthmus radiofrequency ablation visualised under direct endoscopic visualisation

Abstract

Introduction: Various tools such as the Pulmonary Vein Ablation Catheter (PVAC®; Medtronic Inc.) have been developed to treat atrial fibrillation. Methods: Prospective, single operator observational registry of PVAC. The first 51 patients undergoing pulmonary vein isolation with the PVAC-Gold (second generation) were included in theanalysis. Intra cardiac echocardiography (ICE) was used to guide transseptal and positioning of the PVAC catheter in 47 of 51 cases. Results:Median agewas 61 years of age (range 34-84). 64% were male. 65% had paroxysmal atrial fibrillation. The averageCHADS2-VAScwas1.9 (range0-5). 48%wereonwarfarin, the remainder on novel oral anticoagulants. Themedian time (from needle-to-skin to catheters out) for ablation of paroxysmal atrial fibrillation was 78min (IQR range 61-123min), and persistent atrial fibrillation was 124min (IQR range 80189min).Median fluoroscopy timewas 29min (IQR 25-35min; median skin dose 177.5mGy, IQR 25-75% 131-316). The average number of ablations per vein was 5.4. All veins were isolated with the PVAC catheter without the need for additional alternative ablation. There was one groin complication resulting in an additional night in hospital, and two femoral haematomas that did not require additional hospitalisation. All resolvedwithout intervention, andwithout any long-term consequences. There were no perforations, strokes or other significant complications. No patient is more than 12 months post ablation yet and efficacy assessment will need long-term follow-up. Conclusion: Phased RF offers an alternative safe and efficient approach to pulmonary vein isolation.