Procedural and biophysical indicators of durable pulmonary vein isolation during cryoballoon ablation of atrial fibrillation

Aryana, Arash; Mugnai, Giacomo; Singh, Sheldon M.; Pujara, Deep; Asmundis, Carlo de; Singh, Steve K.; Bowers, Mark R.; Brugada, Pedro; Reddy, Vivek Y.; O’Neill, Padraig Gearoid; Chierchia, Gian‐Battista

doi:10.1016/j.hrthm.2015.10.033

Cited by 140 publications

(182 citation statements)

References 13 publications

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“…The phase change is endothermic, causing the removal of heat from the target tissue (ie, the Joule‐Thomson effect) and finally resulting in a cryogenic lesion, as cells undergo necrosis and apoptosis 16 . This phenomenon on the cellular level has been then validated on the clinical one, as demonstrated by some studies which examined the relation between CbA‐NT and long‐term PVI durability 2,3,17 . Moreover, it has been proved that temperature drop during AF is faster and lower freezing values can be achieved in patients with ongoing AF during the procedure 18 .…”

Section: Discussionmentioning

confidence: 95%

Pulmonary veins anatomical determinants of cooling kinetics during second‐generation cryoballoon ablation

Borio

Maj

Rizzo

et al. 2020

Cardiovasc electrophysiol

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Aim The aim of the study was to investigate the role of anatomical characteristics of the pulmonary veins (PVs) determining cooling kinetics during second‐generation cryoballoon ablation (CbA). Methods and Results we enrolled all consecutive patients who underwent CbA for symptomatic atrial fibrillation in our center from January 2019 to March 2019. All patients had complete computed tomography scans of the heart before the ablation. Anatomical characteristics were tested for prediction of a nadir temperature (NT) ≤ −48°C. Significant differences were noted among PV max diameter (20.8 ± 2.8 vs 18.5 ± 2.5 mm; P < .001); PV minimum diameter (15.2 ± 3.0 vs 13.0 ± 3.1 mm; P < .001); PV area (268.1 ± 71.9 vs 206.2 ± 58.7 mm2; P < .001); PV ovality (1.4 ± 0.3 vs 1.5 ± 0.3; P = .005); and PV trunk length (27.4 ± 7.4 vs 21.3 ± 6.5 mm; P < .001). A scoring system was created by assigning one point each ranging from 0 (best anatomical combination) to 5. In the group with a score of 0, 94.0% of the CbA could reach a NT ≤ −48°C whereas with a score of 5, only 29.0% (P < .001). Left superior pulmonary vein with short trunk length and acute angle of PV branch was significantly associated with warmer NT (11.8% satisfactory CbA; P = .003). Regarding right inferior pulmonary vein, trunk length (P = .004), maximum diameter (P = .044), and transverse angle (P = .008) were independently associated with good NT. Conclusion Anatomical PV features are associated with cooling kinetics and an anatomical score could predict lower NT during second‐generation CbA. Specific characteristics were identified for inferior PV. Although heart imaging is not mandatory prior CbA, it can be a useful tool to predict cooling kinetics.

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Section: Discussionmentioning

confidence: 95%

Pulmonary veins anatomical determinants of cooling kinetics during second‐generation cryoballoon ablation

Borio

Maj

Rizzo

et al. 2020

Cardiovasc electrophysiol

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“…Improved identification of PV potential disappearance has several potential clinical benefits. (1) Ineffective cryoballoon application can be stopped in cases of persistent LA–PV conduction continuing over 60 seconds of balloon freezing, because a time to PVI of ≤60 seconds significantly predicted PVI durability . (2) Time to PVI has been reported as a marker for the estimation of AF recurrence after cryoballoon PVI .…”

Section: Discussionmentioning

confidence: 99%

“…Next, the balloon was inflated and the balloon catheter was further advanced to the PV ostium as guided by the PV mapping catheter. After confirmation of PV occlusion by pulmonary venography, cryoablation commenced and continued for 180 seconds if confirmation of LA–PV disconnection or a PV temperature <−40°C could be achieved within the initial 60 seconds . If these were not achieved during the initial 60 seconds, we stopped the freezing and changed the positions of the PV mapping catheter and the balloon catheter in order to reocclude the PV.…”

Section: Methodsmentioning

confidence: 99%

A decapolar 25‐mm‐diameter circular mapping catheter with improved detection of pulmonary vein potential disappearance in cryoballoon ablation

Matsuda

Masuda

Asai

et al. 2019

Journal of Arrhythmia

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Background Disappearance of pulmonary vein ( PV ) potentials is an important indicator of successful PV isolation during cryoballoon ablation. Conventional octapolar 20‐mm‐diameter circular PV mapping catheters occasionally fail to identify persistent PV potentials. A new decapolar 25‐mm‐diameter circular PV mapping catheter has been introduced to improve the detection of PV potentials and their elimination. We compared the detection rates of PV potential disappearance between the decapolar and the octapolar PV mapping catheters. Methods and Results A total of 44 consecutive patients (175 PV s) undergoing initial cryoballoon ablation for atrial fibrillation were included. The decapolar catheter was used for 79 (45%) PV s in 20 (45%) patients. There was no difference in left atrial diameter or PV diameter in patients mapped with the two catheters. The decapolar mapping catheter demonstrated a significantly higher detection rate of PV potential disappearance than the octapolar catheter. The need for touch‐up ablation was similar between the two groups (5% vs 8%, P = 0.39). When PV potentials were identified, the decapolar catheter detected significantly higher‐amplitude PV potentials than the octapolar catheter. In multivariate analysis, use of the decapolar catheter was an independent predictor of the detection of PV potential disappearance. Conclusions The decapolar PV mapping catheter demonstrated improved detection of PV potential disappearance in cryoballoon PV isolation.

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“…While time to PV electrical isolation algorithms is now widely used to titrate the cryoapplication time it requires consistent PV potentials. Aryana et al reported that 81% of PVs sleeve potentials where recorded forcing the clinician to apply prolong freeze times to these veins. Furthermore, despite utilizing the time to isolation still, some of the cryoapplications fail to achieve long‐term PV isolation .…”

Section: Introductionmentioning

confidence: 99%

“…Aryana et al reported that 81% of PVs sleeve potentials where recorded forcing the clinician to apply prolong freeze times to these veins. Furthermore, despite utilizing the time to isolation still, some of the cryoapplications fail to achieve long‐term PV isolation . PV reconnection may reflect tissue stunning as a result of uneven ice formation .…”

Section: Introductionmentioning

confidence: 99%

Determination of single cryoablation outcome within 30 to 60 seconds of freezing based on ice impedance

Avitall

Lizama

Kalinski

et al. 2019

Cardiovasc electrophysiol

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BackgroundA direct indicator of effective pulmonary vein isolation (PVI) based on early ice formation is presently lacking.ObjectiveThe initial impedance rise within 30 to 60 seconds (sec) of single cryoablation relating to ice on the distal surface of the cryoballoon could; predict effective PVI with early termination, the need for prolonging the cryoablation, or failure to achieve effective ablation.MethodsImpedance measurements were taken between two ring electrodes, at the anterior balloon surface and at the shaft behind the balloon. Ice covering the anterior ring leads to impedance rise. Single cryoablation (eight animals, 37 veins) was applied for 90 to 180 sec. Cryoapplication was terminated if the impedance reached ≥500 Ω. Impedance levels at ≤60 sec of cryoablation were divided into three groups based on the characteristics of the impedance rise. PVI was confirmed acutely and at 45 ± 9 days recovery by electrophysiology mapping and histopathology.ResultsAt 60 sec of freezing, an impedance rise of 34.1 ± 15.2 Ω (13‐50 Ω) and slope of the impedance rise (measured during 15‐30 sec of cryoapplication) less than 1 Ω/sec resulted in failed PVI. An impedance rise of 104.4 ± 31.5 Ω (76‐159 Ω) and slope of 2 Ω/sec resulted in 100% PVIs. An impedance rise of 130.9 ± 137.8 Ω (40‐590 Ω) and slope of 10 Ω/sec resulted in 100% PVIs with early termination at 90 sec.ConclusionThe efficacy of single cryoablation can be defined within 30 to 60 sec based on ice impedance. Three unique impedance profiles described in this investigation are associated with the uniformity and thickness of the ice buildup on the anterior surface of the balloon. One cryoablation with an adequate impedance rise is needed for successful outcomes.

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Procedural and biophysical indicators of durable pulmonary vein isolation during cryoballoon ablation of atrial fibrillation

Abstract: A time to effect of ≤60 seconds and an iTT0 of ≥10 seconds significantly predict PV isolation durability after the cryoballoon ablation of AF. If both criteria are met, the likelihood of PV reconnection may be exceedingly low.

Cited by 140 publications

References 13 publications

Pulmonary veins anatomical determinants of cooling kinetics during second‐generation cryoballoon ablation

Pulmonary veins anatomical determinants of cooling kinetics during second‐generation cryoballoon ablation

A decapolar 25‐mm‐diameter circular mapping catheter with improved detection of pulmonary vein potential disappearance in cryoballoon ablation

Determination of single cryoablation outcome within 30 to 60 seconds of freezing based on ice impedance

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