Cryoballoon Pulmonary Vein Isolation Guided by TEE
TEE-Guided Cryoballoon PV Isolation.
Background: Pulmonary vein (PV) isolation using a balloon-mounted cryoablation system is a new technology for the percutaneous treatment of atrial fibrillation (AF). Transesophageal echocardiography (TEE) allows real-time visualization of cryoballoon positioning and successful vein occlusion via color Doppler. We hypothesized that PV mechanical occlusion monitored with TEE could predict effective electrical isolation.
Methods: We studied 124 PVs in 30 patients. Under continuous TEE assessment, a cryoballoon was placed in the antrum of each PV aiming for complete PV occlusion as documented by color Doppler. At the end of the procedure, PV electrical isolation was evaluated using a circumferential mapping catheter.
Results: Of the 124 PVs studied, 123 (99.2%) could be visualized by TEE: the antrum was completely visualized in 80 of them (64.5%), partially in 36 (29.0%), and only disappearance of proximal flow could be observed in the remaining 7 PVs (5.7%). Vein occlusion could be achieved in 111 of the 123 (90.2%) visualized PVs. Postinterventional mapping demonstrated electrical isolation in 109 of 111 occluded PVs (positive predictive value 98.2%) and only in 1 of 12 nonoccluded PVs (negative predictive value 91.7%, P < 0.001). After a mean follow-up of 7.4 ± 3.7 months, 73.3% of patients remained in sinus rhythm without antiarrhythmic drugs.
Conclusion: Color Doppler documented PV occlusion during cryoballoon ablation can predict effective electrical isolation.
Electrical pulmonary vein (PV) isolation is presently the cornerstone of atrial fibrillation (AF) ablation procedures. Nevertheless, using standard ablation catheters, it remains a technically demanding and time-consuming technique, frequently requiring the use of a 3-dimensional (3D) mapping system. Moreover, radiofrequency ablation in the left atrium (LA) carries a higher complication rate than on the right side, and can lead to thromboembolic events, PV stenosis, or atrioesophageal fistulas. To overcome these problems, new ablation devices and energies such as the cryoballoon have been recently introduced.
With the cryoballoon, cryoenergy is applied using an occluding balloon system to create circumferential lesions around the PV. Correct positioning of the cryoballoon in the antrum of the PV plays an important role in the safety and efficacy of the procedure. In all previously published studies, PV occlusion was verified using repetitive contrast fluid injections. However, this technique lacks precision in localizing a possible leak and does not give any further information on the surrounding anatomy.
Transesophageal echocardiography (TEE) allows real-time visualization of PV anatomy, as well as of all surrounding atrial structures. It therefore permits online monitoring of balloon positioning and PV occlusion via color Doppler, and might improve both safety and efficacy of the procedure. In this study, we hypothesized that TEE-guided documentation of mechanical occlusion of the PV during cryoballoon ablation procedures could predict effective electrical PV isolation.
Abstract and Introduction
Abstract
TEE-Guided Cryoballoon PV Isolation.
Background: Pulmonary vein (PV) isolation using a balloon-mounted cryoablation system is a new technology for the percutaneous treatment of atrial fibrillation (AF). Transesophageal echocardiography (TEE) allows real-time visualization of cryoballoon positioning and successful vein occlusion via color Doppler. We hypothesized that PV mechanical occlusion monitored with TEE could predict effective electrical isolation.
Methods: We studied 124 PVs in 30 patients. Under continuous TEE assessment, a cryoballoon was placed in the antrum of each PV aiming for complete PV occlusion as documented by color Doppler. At the end of the procedure, PV electrical isolation was evaluated using a circumferential mapping catheter.
Results: Of the 124 PVs studied, 123 (99.2%) could be visualized by TEE: the antrum was completely visualized in 80 of them (64.5%), partially in 36 (29.0%), and only disappearance of proximal flow could be observed in the remaining 7 PVs (5.7%). Vein occlusion could be achieved in 111 of the 123 (90.2%) visualized PVs. Postinterventional mapping demonstrated electrical isolation in 109 of 111 occluded PVs (positive predictive value 98.2%) and only in 1 of 12 nonoccluded PVs (negative predictive value 91.7%, P < 0.001). After a mean follow-up of 7.4 ± 3.7 months, 73.3% of patients remained in sinus rhythm without antiarrhythmic drugs.
Conclusion: Color Doppler documented PV occlusion during cryoballoon ablation can predict effective electrical isolation.
Introduction
Electrical pulmonary vein (PV) isolation is presently the cornerstone of atrial fibrillation (AF) ablation procedures. Nevertheless, using standard ablation catheters, it remains a technically demanding and time-consuming technique, frequently requiring the use of a 3-dimensional (3D) mapping system. Moreover, radiofrequency ablation in the left atrium (LA) carries a higher complication rate than on the right side, and can lead to thromboembolic events, PV stenosis, or atrioesophageal fistulas. To overcome these problems, new ablation devices and energies such as the cryoballoon have been recently introduced.
With the cryoballoon, cryoenergy is applied using an occluding balloon system to create circumferential lesions around the PV. Correct positioning of the cryoballoon in the antrum of the PV plays an important role in the safety and efficacy of the procedure. In all previously published studies, PV occlusion was verified using repetitive contrast fluid injections. However, this technique lacks precision in localizing a possible leak and does not give any further information on the surrounding anatomy.
Transesophageal echocardiography (TEE) allows real-time visualization of PV anatomy, as well as of all surrounding atrial structures. It therefore permits online monitoring of balloon positioning and PV occlusion via color Doppler, and might improve both safety and efficacy of the procedure. In this study, we hypothesized that TEE-guided documentation of mechanical occlusion of the PV during cryoballoon ablation procedures could predict effective electrical PV isolation.
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