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

Abstract

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

Efficacy and safety of the second‐generation cryoballoon ablation for the treatment of persistent atrial fibrillation in elderly patients

“…Our routine PVI protocol using the CB‐A has been previously described 7 . In brief, a loading dose of 100 U/kg of heparin was given prior to transseptal access, thereafter an ACT of >300 seconds was maintained.…”

Transseptal puncture for left atrial ablation: Risk factors for cardiac tamponade and a proposed causative classification system

“…Transseptal puncture (TSP) is the preferred route of access to the left atrium for catheter ablation and structural intervention 1 . Recent therapeutic developments, including the advent of cryoballoon pulmonary vein isolation, percutaneous left atrial appendage occlusion, and transcatheter mitral valve intervention, necessitate the delivery of wide‐bore sheaths and devices across the interatrial septum 2–4 . Whilst innovations in intracardiac imaging, needle technology, guidewire assistance, and 3D electro‐anatomical mapping have reduced procedural morbidity, TSP remains a high risk step during left‐sided catheter‐based interventions 5–7 …”

Use of a novel integrated dilator-needle system in cryoballoon procedures: a zero-exchange approach

“…Although we present an over-the-wire TSP technique, Ströker et al previously demonstrated the safety and efficacy of a direct approach with the FlexCath Advance sheath using an over-the-needle technique [ 19 ]. By preshaping the sheath-dilator assembly, they could target the low anterior or medial portion of the fossa ovalis.…”