Effect of air removal with extracorporeal balloon inflation on incidence of asymptomatic cerebral embolism during cryoballoon ablation of atrial fibrillation

Tokuda, Michifumi; Matsuo, Seiichiro; Kato, Mika; Sato, Hidenori; Oseto, Hirotsuna; Okajima, Eri; Ikewaki, Hidetsugu; Isogai, Ryota; Tokutake, Kenichi; Yokoyama, Kenichi; Narui, Ryohsuke; Tanigawa, Shin‐ichi; Yamashita, Seigo; Inada, Keiichi; Yoshimura, Michihiro; Yamane, Teiichi

doi:10.1016/j.hrthm.2017.05.035

Cited by 18 publications

(15 citation statements)

References 16 publications

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“…The incidence of SCILs in the CBA and HBA groups was 21.5% and 13.8%, respectively, and that in the CBA group was similar to that reported in recent studies with a CB‐based AF ablation . To the best of our knowledge, there have been no previous studies reporting the incidence of silent cerebral embolisms after radiofrequency HBA of AF.…”

Section: Discussionsupporting

confidence: 87%

“…Balloon‐based AF ablation, as well as radiofrequency catheter‐based AF ablation, has a potential risk for periprocedural embolic complications. Symptomatic embolisms, including ischemic strokes, transient ischemic attacks (TIAs), and systemic emboli, after cryoballoon ablation (CBA) of AF are rare occurrences, while silent cerebral emboli detected by brain magnetic resonance (MR) imaging are relatively common, and have been reported to be observed in 4.3% to 50% of patients undergoing CBA . So far, limited data are available on the incidence of symptomatic and silent embolisms after radiofrequency HotBalloon ablation (HBA) of AF …”

Section: Introductionmentioning

confidence: 99%

“…Adequate periprocedural anticoagulation using oral anticoagulants plays an important role in preventing thromboembolic complications associated with AF ablation . The majority of the previous studies with brain MR imaging after CBA consisted of patients receiving periprocedural oral anticoagulation with warfarin, while a few studies included some patients with direct oral anticoagulants (DOACs) in addition to those with warfarin.…”

Section: Introductionmentioning

confidence: 99%

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Postablation cerebral embolisms in balloon‐based atrial fibrillation ablation with periprocedural direct oral anticoagulants: A comparison between cryoballoon and HotBalloon ablation

Nakamura

Sasaki

Take

et al. 2018

Cardiovasc electrophysiol

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Introduction: This prospective observational study aimed to investigate the incidence of symptomatic and silent cerebral embolisms after balloon-based ablation of atrial fibrillation (AF) in patients receiving periprocedural anticoagulation with direct oral anticoagulants (DOACs), and compare that between cryoballoon and HotBalloon ablation (CBA and HBA). Methods and Results:We enrolled 123 consecutive AF patients who underwent a balloon-based pulmonary vein isolation (PVI) and brain magnetic resonance (MR) imaging after the ablation procedure (CBA, n = 65; HBA, n = 58). The DOACs were continued in 62 patients throughout the periprocedural period and discontinued in 61 on the procedural day. Intravenous heparin was infused to maintain an activated clotting time of 300 to 400 seconds during the procedure. No symptomatic embolisms occurred in this series. Silent cerebral ischemic lesions (SCILs) were observed on MR imaging in 22 patients (17.9%), and the incidence of SCILs did not significantly differ between the CBA and HBA groups (21.5 vs 13.8%; P = 0.263).According to a multivariate logistic regression analysis, an older age was an independent positive predictor of SCILs (odds ratio, 1.062; 95% CI, 1.001-1.126; P = 0.046), but neither the balloon catheter type nor periprocedural continuation or discontinuation of the DOACs were significant predictors. The incidence of major and minor bleeding complications was comparable between the CBA and HBA groups (1.5 vs 0%, P = 0.528; 7.7 vs 5.2%, P = 0.424).Conclusions: Both CBA and HBA of AF revealed a similar incidence of postablation cerebral embolisms. Elderly patients may be at a risk of SCILs after a balloon-based PVI with periprocedural DOAC treatment. K E Y W O R D S atrial fibrillation, catheter ablation, cryoballoon, direct oral anticoagulant, embolism, HotBalloon J Cardiovasc Electrophysiol. 2019;30:39-46.wileyonlinelibrary.com/journal/jce

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Section: Discussionsupporting

confidence: 87%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Postablation cerebral embolisms in balloon‐based atrial fibrillation ablation with periprocedural direct oral anticoagulants: A comparison between cryoballoon and HotBalloon ablation

Nakamura

Sasaki

Take

et al. 2018

Cardiovasc electrophysiol

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“…Without the need for an additional sheath exchange, the CBS‐N technique decreases the risk to introduce gas bubbles, thrombi, or embolic particle debris in the LA. Likewise, removal of air bubbles with extracorporeal balloon inflation before utilization was recently described as another modified procedural step during CB‐A ablation in order to reduce the rate of silent strokes . In our study using the CBS‐N approach, left‐sided thromboembolic events were noted in four patients (two transient ST elevations, two TIAs), both with a similar incidence rate compared to a cohort using the CBS‐W approach in this study, and as described previously .…”

Section: Discussionsupporting

confidence: 76%

Over‐the‐needle trans‐septal access using the cryoballoon delivery sheath and dilator in atrial fibrillation ablation

Ströker

Greef

Schwagten

et al. 2019

Pacing Clinical Electrophis

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Background:In the setting of second-generation cryoballoon (CB2) ablation, left atrial (LA) access is generally achieved using a standard sheath (SS) that is exchanged for the 15Fr cryoballoon delivery sheath (CBS) and dilator over a long wire (CBS over-the-wire technique, CBS-W). Our objective was to evaluate the direct use of the CBS to gain LA access, by advancing the latter over the trans-septal needle (CBS over-the-needle technique, CBS-N), under transesophageal echocardiographic (TEE) guidance. Methods: Consecutive patients who underwent CB2 ablation with the CBS-N technique were evaluated for feasibility of gaining LA access using TEE guidance and fluoroscopy views. Complications related to the LA access were compared with a matched CBS-W control group. Subanalysis (30 CBS-W vs 30 CBS-N patients) evaluated time-to-LA of the CBS: time from superior vena cava (with SS vs CBS) to LA insertion of the CBS, after exchange or directly, respectively.Results: LA access could be achieved in all 505 patients of the CBS-N group, without technique modification or additional equipment. Challenging interatrial septa were noted in 13% of these patients: previous atrial septal defect repair (1%), hypermobile (10%), aneurysmal (1%), and abnormally thickened/fibrotic (1%). Incidence of complications was similar to the CBS-W group. Subanalysis showed a shorter time-to-LA in the CBS-N versus CBS-W group, 72 ± 46 seconds versus 293 ± 180 seconds, P < .001. Conclusions:Our study showed that the CBS-N technique is feasible and safe under echocardiographic guidance. Without sheath exchange, it simplifies the CB2 procedure, is less costly, time sparing, and might reduce the risk of air embolism. K E Y W O R D S atrial fibrillation ablation, FlexCath sheath, second-generation cryoballoon, trans-septal access 1 INTRODUCTION Pulmonary vein (PV) isolation is currently an established treatment for symptomatic atrial fibrillation (AF). 1 In recent years, cryoballoon (CB) ablation has emerged as a valid alternative to traditional point-bypoint radiofrequency (RF) ablation, rendering the PV isolation proce-dure highly standardized and reproducible. 2,3 In the setting of secondgeneration cryoballoon (CB-A, Arctic Front Advance TM , Medtronic Inc., Minneapolis, MN, USA) ablation, left atrial (LA) access is generally achieved using a standard trans-septal (TS) sheath that is then exchanged for the 15-Fr cryoballoon delivery sheath (CBS) (FlexCath Advance TM , Medtronic Inc.) and its dilator over a long stiff wire (CBS 868

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“…13,14) The procedure in order to prevent procedure-related embolic events during cryoballoon ablation has been assessed, however, such a procedure was able to reduce the incidence from 23.3 to 4.7 %. 6) We considered that other factors might contribute to the embolic events associated with the cryoballoon applications. We performed a clinical study regarding the blood coagulation status during cryoballoon ablation under dabigatran treatment.…”

Section: Discussionmentioning

confidence: 99%

Blood Coagulation Status during Cryofreezing Ablation and Effects of the Direct Anticoagulants Dabigatran and Edoxaban

et al. 2020

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Cryoballoon ablation is an established catheter-based approach to treat atrial fibrillation (AF). However, thromboembolic events cannot be avoided during cryoablation. There is little data regarding the blood coagulation status during freezing. The thrombin antithrombin complex (TAT) and prothrombin fragment 1+2 (F 1+2) of patient blood were measured during cryoballoon application when the cryoballoon temperature reached the nadir in 63 AF patients. TAT was also measured from porcine blood during cryoballoon freezing in 5 pigs. The TAT and F 1+2 increased from 6.60 ± 5.65 to 9.16 ± 7.28 ng/mL (P = 0.004) and from 279.6 ± 146.4 to 323.6 ± 169.1 pmol/L (P = 0.003) between the control and during freezing, respectively. The TAT increased from 0.46 to 0.87 ng/mL during freezing compared to that of pre-freezing (P < 0.05), and it returned to 0.39 ng/mL in 30 minutes after an intravenous edoxaban administration (N.S.). Dabigatran failed to exert sufficient anticoagulant effects during cryofreezing. In contrast, intravenous edoxaban seemed to provoke anticoagulation effects under extreme low temperature circumstances.

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Effect of air removal with extracorporeal balloon inflation on incidence of asymptomatic cerebral embolism during cryoballoon ablation of atrial fibrillation

Cited by 18 publications

References 16 publications

Postablation cerebral embolisms in balloon‐based atrial fibrillation ablation with periprocedural direct oral anticoagulants: A comparison between cryoballoon and HotBalloon ablation

Postablation cerebral embolisms in balloon‐based atrial fibrillation ablation with periprocedural direct oral anticoagulants: A comparison between cryoballoon and HotBalloon ablation

Over‐the‐needle trans‐septal access using the cryoballoon delivery sheath and dilator in atrial fibrillation ablation

Blood Coagulation Status during Cryofreezing Ablation and Effects of the Direct Anticoagulants Dabigatran and Edoxaban

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