Zero sheath exchange with VersaCross RF wire and FlexCath in cryoballoon AF ablation: A comparative study on procedural efficiency and safety.

POSTER PRESENTATIONS

Pulmonary vein isolation in a patient with achalasia and megaesophagus

Long-standing persistent atrial fibrillation ablation without use of fluoroscopy in a patient with cor triatriatum

ORAL PRESENTATION

Patient: Female, 61Final Diagnosis: Iatrogenic arteriovenous fistula and atrial septal defect following cryoballoon ablation for atrial fibrillationSymptoms: Exercise intolerance • exertional dyspnea • peripheral edemaMedication: —Clinical Procedure: Catheter ablation for persistent atrial fibrillation, corrective surgery for arteriovenous fistulaSpecialty: CardiologyObjective:Diagnostic/therapeutic accidentsBackground:Catheter ablation for atrial fibrillation is an important therapeutic intervention. One of the most frequent complications of this procedure is vascular issues including arteriovenous fistula. Iatrogenic atrial septal defect (IASD) has been reported as a complication of transseptal puncture; however, no data are available demonstrating any coexistent of arteriovenous fistula with IASD.Case Report:A 61-year-old female patient was admitted to our center for catheter ablation for persistent atrial fibrillation. Her past medical history was significant for cryoballoon ablation for atrial fibrillation in 2015, which was subsequently complicated by hematoma and arteriovenous fistula at puncture site. After general surgery consultation, the patient was qualified for conservative treatment. To exclude left atrial thrombus before redo procedure, transesophageal echocardiography was performed which visualized the presence of 9-mm atrial septal defect with left-to-right shunting, detecting right-to-left shunting using Valsalva maneuver. No significant valvular abnormalities were identified. The next day, pulmonary vein isolation for atrial fibrillation was performed. One month later, a control transthoracic echocardiogram (TTE) revealed hemodynamic significant left-to-right shunting with Qp/Qs 2.0 and high probability of pulmonary hypertension. Vascular surgery for arteriovenous fistula was successfully performed in October 2018. Subsequent TTE, performed a month later, confirmed no left-to-right shunting and no signs of pulmonary hypertension or diminishment of the right atrium.Conclusions:Vascular access during catheter ablation for atrial fibrillation may result in arteriovenous fistula. This condition might affect right atrium pressure leading to increased diameter of previous puncture site at the interatrial septum, causing IASD with significant shunting. In this group of patients, arteriovenous fistula should be treated as soon as possible.

During the past decade, catheter ablation of atrial fibrillation (AF) has emerged as an important treatment option for patients with symptomatic AF refractory to ≥1 antiarrhythmic agents. Electric isolation of the pulmonary vein musculature (PVI) has been identified as the primary end point for both catheter- and surgical-based AF ablation procedures.1 What is less clear is whether the addition of “linear lesions” or ablation of atrial sites demonstrating complex atrial electrograms improves outcome for patients with paroxysmal, persistent, or long-standing persistent AF.2,3 This issue remains an area of active discussion, debate, and investigation. Article see p 269 In this issue of Circulation: Arrhythmia and Electrophysiology , Gaita et al2 report the results of a prospective single-center randomized study of 204 patients who underwent catheter ablation for treatment of paroxysmal or persistent/permanent AF. Patients were stratified according to whether they had paroxysmal (n=125) or persistent/permanent (n=79) AF and were then randomized in a 2:1 fashion to undergo PVI alone or PVI combined with a “roof line” and a “left mitral line.” Follow-up visits that included an ECG, 24-hour Holter, and an echocardiogram were set up at 1, 3, 6, 12, 18, 24, and 30 months and then every year thereafter. If a patient experienced symptoms between follow-up visits, an event monitor was prescribed. A recurrence was defined as a symptomatic or asymptomatic episode of AF or atrial flutter lasting ≥30 seconds after a 2-month blanking period. Patients who developed a recurrence after the blanking period were offered a repeat ablation procedure. The outcome of ablation was evaluated at 12 months of follow-up and at completion of the study. Each patient was followed for a minimum of 3 years. Among the 125 patients with paroxysmal AF, the single-procedure success rate at 12 months was 46% with PVI alone versus …

Successful transseptal puncture and cryoballoon ablation of symptomatic paroxysmal atrial fibrillation via jugular access in a patient with bilateral thrombotic femoral vein occlusion

Catheter ablation for persistent atrial fibrillation in an elderly patient with cor triatriatum sinister

Research Needs and Priorities for Catheter Ablation of Atrial Fibrillation

Evidence from animal and human studies suggests that cryoablation might be associated with a lesser inflammatory response and activation of coagulation compared with radiofrequency ablation. The study was aimed at comparing the effect of cryoballoon and radiofrequency catheter ablation of paroxysmal atrial fibrillation on markers of myocardial damage, inflammation, and activation of coagulation. Forty-one patients received either cryoballoon (n= 23) or radiofrequency (n= 18) ablation of atrial fibrillation. We measured troponinI, high-sensitivity CRP, and interleukin6 at baseline from the cubital vein, and from the right and left atrium before and after ablation, and from the cubital vein the following day. Prothrombin fragments 1+ 2, soluble P‑selectin, and D‑dimer were measured before and after ablation from both atria. We observed higher troponinI release in the cryoballoon than in the radiofrequency group (7.01mcg/l (interquartile range [IQR]: 5.30-9.09) vs 2.32mcg/l (IQR: 1.45-2.98), p <0.001). The levels of inflammatory markers (high-sensitivity CRP and interleukin6) in the two groups were comparable, as were the levels of markers of coagulation activation. Procedure duration, fluoroscopy times, and mid-term success (23months, IQR 7-32) of the two groups were also comparable. Cryoballoon ablation of atrial fibrillation causes more significant myocardial damage, that is, more extensive ablation lesions, compared with radiofrequency catheter ablation. However, no major differences between these two ablation techniques with regard to the inflammatory response and activation of the coagulation system were observed.

Reduction of radiation exposure during atrial fibrillation ablation using a novel fluoroscopy image integrated 3-dimensional electroanatomic mapping system: A prospective, randomized, single-blind, and controlled study.

Unusual esophageal injury after atrial fibrillation ablation: Early diagnosis and treatment to optimize outcomes

Bailout Atrial Balloon Septoplasty to Overcome Challenging Left Atrial Transseptal Access for Catheter Ablation of Atrial Fibrillation.

Background: The demonstration of pulmonary vein (PV) occlusion is routinely performed and considered a prerequisite for successful cryoballoon (CB) ablation of atrial fibrillation (AF). The purpose of this study was to assess the feasibility and impact on procedural parameters and outcome of a standardized procedural protocol without demonstrating PV occlusion.Methods and Results: Consecutive patients undergoing CB pulmonary vein isolation (PVI) were studied. After cMRI assessment, patients treated by PVI using a novel no-contrast (NC) protocol without routine contrast injections to demonstrate PV occlusion (NC group) were compared to patients undergoing PVI with contrast injections to demonstrate PV occlusion (standard group). One hundred patients with paroxysmal or persistent AF (age 61 ± 10 years, ejection fraction 59 ± 11%, left atrial volume index 37.2 ± 2.0 mL/m2) were studied. The NC protocol was feasible in 72 of 75 patients (96%). Total procedure time and fluoroscopy time were 64.0 ± 14.1 min and 11.0 ± 4.6 min in the NC group and 92.0 ± 25.3 min and 18.0 ± 6.0 min in the standard group, respectively (all p < 0.001). Dose area product was 368 ± 362 cGy*cm2 in the NC group compared to 1928 ± 1541 cGy*cm2 in the standard group (p < 0.001). Forty-five of 75 patients (60%) in the NC group and 16 of 25 patients (64%) in the standard group remained in stable sinus rhythm after a single PVI and a 1-year follow-up (p = 0.815).Conclusions: Performing CB ablation without using contrast injections to demonstrate PV occlusion was feasible, resulted in reduced radiation exposure, and increased the efficiency of the procedure.

Occlusion tool software for pulmonary vein occlusion verification in atrial fibrillation cryoballoon ablation to avoid the use of contrast injection