Pulmonary vein reconnection following cryo-ablation: Mind the “Gap” in the carinae and the left atrial appendage ridge

Abstract

Pulmonary vein (PV) isolation (PVI) remains cornerstone to ablation of atrial fibrillation (AF). For effective and durable PVI and thus fewer AF recurrences, lesion gaps in transmurality and contiguity responsible for PV reconnection (PVR) could only be addressed when one is cognizant of the potential location and sites where these lesion characteristics may be more prevalent and responsible for PVR. In the case of RF ablation, newer technologies incorporating contact force, time and power with automated monitoring of lesion formation, paying attention to difficult areas (carinae, left superior PV-LAA ridge, right inferior PV) and measuring inter-lesion distance may provide the tools to reduce PVR. On the other hand, the improved thermodynamic characteristics of the latest generation of cryoballloons and operator dexterity to achieve better PV occlusion, may be crucial determinants towards the direction of reduced PVR. Whether newer visualization tools, more vigilant testing during the index ablation procedure in these particular regions, prolonging or adding cryothermic applications, waiting longer to test for entrance and exit block, and/or use of provocative drug testing (isoproterenol/adenosine challenge) might help prevent future PVRs awaits further studies.

Fast anatomical mapping of the carina and its implications for acute pulmonary vein isolation

“… 7 , 8 , 9 Therefore data referring to electrical and anatomical characteristics of the carina region have been published recently. 10 , 11 In our present study, we observed frequency and distribution of carina‐related PV conduction after encircling of ipsilateral PVs during PVI. Furthermore, we hypothesized that carina width can be measured utilizing a fast anatomical mapping (FAM) of the LA and its conjunctive PV, which is generated routinely during PVI.…”

“…Several studies have hinted toward a role of the intervenous carina for persistent conduction between pulmonary veins (PV) and the left atrium (LA) due to an epicardial connection between the carina region and both atria 7‐9 . Therefore data referring to electrical and anatomical characteristics of the carina region have been published recently 10‐11 . In our present study, we observed frequency and distribution of carina‐related PV conduction after encircling of ipsilateral PVs during PVI.…”

Radiofrequency catheter ablation for re-do procedure after single-shot pulmonary vein isolation with pulsed field ablation for paroxysmal atrial fibrillation: case report

“…The most frequently observed areas for PV reconnection were found to be the anterior region of the right superior PV, the posterior-inferior segment of the right inferior PV, and the posterior-superior portion of the left superior PV. These findings align with those noted in our case ( 6 , 9 ). The geometry of the PFA catheter and the applied contact force may also play crucial roles during ablation procedures with PFA ( 8 ).…”

“…Durable PVI remains the goal of AF ablation strategies. Rates of PVs reconnections following PVI employing either cryoballoon or radiofrequency ablation have been reported to vary widely, ranging from 22 to 38 percent and reaching as high as 62.5 percent in some cases ( 6 ).…”

Electrophysiological findings during re-do procedures after single-shot pulmonary vein isolation for atrial fibrillation with pulsed field ablation

“…Reported rates of PV reconnection following PVI with cryoballoon or radiofrequency ablation range from ∼22–38% to as high as 62,5% (Fig. 4 ) [ 9 ]. There is a need for an energy source that can create transmural lesions and durable PVI without collateral damage.…”