Prevalence of gastric hypomotility after additional cryoballoon ablation of the left atrial roof.

INTRODUCTION: Gastric hypomotility (GH) is a major complication of atrial fibrillation (AF) ablation. We aimed to clarify whether additional cryoballoon ablation (CBA) of the left atrial (LA) roof is associated with GH. METHODS AND RESULTS: This study included 54 patients with non-paroxysmal AF who underwent CBA for pulmonary vein isolation and of the LA roof line. GH was defined according to the results of esophagogastroscopy performed 2 days after ablation. GH was observed in 10 patients. There were significant differences in LA diameter (LAD), right inferior pulmonary vein (RIPV) diameter, and the height of the LA roof from the point where the LA posterior wall and esophagus make contact between patients with (GH+) and without GH (GH-) (LAD: 41.0 [36.3-41.8] mm vs. 46.5 [42.8-50.0] mm, p < .01; RIPV diameter: 19.7 [19.0-20.5] mm vs. 23.2 [21.2-24.9] mm, p < .01; height of LA roof: 5.7 [5.1-6.1] mm vs. 8.8 [7.1-11.2] mm for, p < .01, respectively). Multivariate analysis revealed that LA roof height was a predictor of GH. Moreover, Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM) scores increased significantly 1 week after ablation (from 1.0 [0.0-2.8] to 5.0 [3.0-11.0], p = .03) in patients with GH. CONCLUSION: The height of the LA roof may be a predictor of GH after CBA of the LA roof line. Additionally, GH-related symptoms may still appear 1 week after ablation.

Vagal Reactions During Laser Balloon Ablation in Patients with Paroxysmal Atrial Fibrillation.

Radiofrequency and cryoballoon applications around the pulmonary veins (PVs) could provoke a vagal reflex (VR) by modulating the intrinsic cardiac autonomic nervous system (ICANS).This study aimed to investigate the incidence, timing, and clinical impact of a VR provoked by a laser balloon application for a PV isolation (PVI).A total of 92 consecutive paroxysmal atrial fibrillation (PAF) patients underwent a laser balloon PVI of PAF. Acute changes in the heart rate and blood pressure were recorded. The heart rate variability (HRV) was tested by Holter ECGs before and at three months following the ablation. Three hundred forty-five out of 363 PVs were successfully isolated (97%) with laser balloon applications. A VR such as sinus bradycardia (26.1%), transient sinus arrest (9.8%), transient atrioventricular block (1.1%), or a blood pressure reduction (8.7%) was observed during the laser balloon applications for the PVI. The follow-up ended at 12 months. The HRV attenuation was comparable before and at three months after the ablation procedure between that with and without a VR (P = 0.14). The PAF recurrence rate was also comparable between the two groups (P = 0.882).The laser balloon PVI often provoked a VR, however, the modulation of the ICANS was temporary and for up to three months as measured by the HRV changes after the ablation, and the freedom from any atrial fibrillation recurrence was comparable regardless of the occurrence of a VR.

Predictors of the "Crosstalk" Phenomenon During Cryoballoon Ablation in Patients with Atrial Fibrillation.

Second-generation cryoballoon (CB) ablation is effective in achieving pulmonary vein (PV) isolation (PVI) in atrial fibrillation (AF) patients. The "crosstalk" (CST) phenomenon has been reported to reduce unnecessary applications during CB ablation. Nevertheless, it is unclear under what conditions the CST phenomenon occurs.To seek the predictors of the CST phenomenon during CB-guided PVI, CST phenomenon in achieving ipsilateral superior PVI during inferior PV ablation was analyzed in AF patients who underwent de novo ablation using CB. CB occlusion status and nadir balloon temperature (NT) were compared in these patients, and all ablated superior PVs were categorized into three groups according to the necessity of the touch up ablation and effectiveness of the phenomenon.Of 1082 superior PVs, 16, 40, and 1026 were classified into the CST success, CST failure, and control groups (unnecessary CST), respectively. The proportion of superior PVs ablated with complete occlusion using the CB was significantly higher in the CST success group than in the other two groups. The proportion of superior PVs ablated with NT ≤ -46°C was higher in the CST success group than in the CST failure group. The CST phenomenon was always observed if CB ablation of the superior PVs was performed with both complete occlusion and NT ≤ -46°C and was almost always ineffective if it did not meet these two criteria (sensitivity, 100%; specificity, 93%).Successful CST ablation was highly predicted if complete PV occlusion and NT ≤ -46°C during CB ablation of the superior PVs were achieved.

Clinical investigation of the durability of the lesions created by left atrial linear ablation with a cryoballoon.

INTRODUCTION: Pulmonary vein isolation (PVI) and linear ablation with a roof line and bottom line on the left atrial (LA) posterior wall (LAPW) can be achieved with a cryoballoon (CB). This study sought to investigate the long-term durability of these linear lesions. METHODS AND RESULTS: Among 290 persistent patients with atrial fibrillation (AF) who had undergone linear ablation with a CB on the roof and bottom line of the LAPW in addition to the PVI, we analyzed those patients who underwent a re-do AF ablation. Arrhythmia recurrence was confirmed in 70 (24%) out of 290 patients, and 47 (16%) patients underwent re-do sessions. At the beginning of the re-do ablation, we examined the reconnection sites of the linear lesions on the LAPW and PVI. Maintenance of the conduction block on the LAPW roof and bottom lines was observed in 35 out of 47 patients (74.5%), and 16 out of 35 patients (45.7%), respectively. The length of the roof line was significantly shorter in patients with preservation of the conduction block on the LAPW roof than in those without (36.2 ± 6.5 mm vs 41.6 ± 4.7 mm, P = .02). CONCLUSION: Durable lesions could be obtained after linear ablation with the CB for the LAPW roof line, especially in those with a relatively short LAPW roof line. However, patients requiring touch-up ablation with radiofrequency were included, and that was associated with a potential financial implication.

Chemical mapping as a predictor of vein of Marshall ethanol ablative effects.

PURPOSE: The aim of this study was to test regional pharmacological effects of an antiarrhythmic agents to predict ablative effects. BACKGROUND: The vein of Marshall (VOM) providing vascular access to myocardial tissue has been used for ablative purposes using ethanol. METHODS: A total of 35 patients (male 21, 63.2 ± 7.8 years old) were included. A balloon-tipped infusion catheter was inserted into the VOM. Endocardial ultrahigh-resolution mapping was performed along the VOM region to record the change in atrial electrograms (AEs) after VOM injection of cibenzoline of 3.5 mg during sustained atrial fibrillation (AF). Subsequently, ethanol was infused into the VOM and ablative region was mapped. RESULTS: In 17 patients (49 %), cibenzoline reduced AEs amplitude by >50%, all of which had also complete elimination of AEs following ethanol (Group A). In 18 patients (Group B), cibenzoline failed to eliminate AEs; yet, in 13 of 18 AEs were eliminated by ethanol. In the remaining five patients, ethanol did not eliminate AE. CONCLUSIONS: Cibenzoline into the VOM could reliably predicts the results of subsequent ethanol infusion into the VOM using ultrahigh-resolution mapping system, which leads to avoid unnecessary permanent lesion creation by ethanol infusion.

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

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.

Experimental Study with Regard to the Effects of Energy Titration of the Laserballoon on the Lesion Creation Using Porcine Myocardium.

Laserballoon-based pulmonary vein isolation has proven to be safe and effective. However, the influence of the laser energy titration on the lesion formation has never been fully investigated. The aim of this study was to determine the relationship between the delivered laser energy and lesion size, as well as the incidence of steam pop.The whole porcine heart was excised, and the left ventricular myocardium was separated into four specimens. Myocardial specimens were embedded in a warm mattress to keep the myocardial temperature around 37°C. The laserballoon was located so that the surface of the laserballoon was attached to the myocardium. The laser energy was irradiated against the surface of myocardium at 5.5, 8.5, 10.0, and 12.0 W for 3, 5, 10, and 20 seconds. The depth, surface area, and lesion volume were measured using a digital vernier caliper.At constant laser energy and time, the lesion size increased significantly with the increasing energy (P < 0.001) and application duration (P < 0.001). The steam pop was provoked when a 12.0 W laser energy was applied for longer than 16 seconds, and it occurred in 2 out of 8 lesions.The laserballoon demonstrated the ability to create a lesion formation in a dose- and time-dependent manner. Steam pop could be provoked with high-energy irradiation.

Cryofreezing catheter ablation of adenosine triphosphate sensitive atrial tachycardia.

INTRODUCTION: Adenosine triphosphate (ATP) sensitive atrial tachycardia (AT) has been treated by radiofrequency catheter ablation. Cryofreezing energy has emerged as a novel energy source for catheter ablation. The aim of this study was to investigate the efficacy and safety of cryofreezing ablation for ATP-sensitive AT. METHODS AND RESULTS: A total of six patients with ATP-sensitive ATs were included in this study. A single atrial extrastimulation was able to initiate and terminate these ATs in all six patients. The electrophysiological findings satisfied the diagnostic criteria of ATP-sensitive AT. The ablation catheter was located at the earliest activation site of atrial excitation during the AT, and cryofreezing energy was delivered through a cryoablation catheter to perform cryomapping at temperature of -30 or -80°C. When cryomapping successfully terminated the ATs, cryoablation at a temperature of -80°C was subsequently performed. The earliest atrial activation during AT was recorded at the Koch's triangle area associated with a distinct intra-atrial activation sequence from that recorded during ventricular pacing. Cryoablation was performed at successful cryomapping sites and resulted in the complete elimination of the AT in all six patients without affecting the bidirectional atrioventricular (AV) nodal conduction. CONCLUSION: Cryofreezing energy was safe and effective in treating ATP-sensitive ATs even in patients with its origins located in the vicinity of the AV node.

Improvement in the Quality of Life and Exercise Performance in Relation to the Plasma B-Type Natriuretic Peptide Level After Catheter Ablation in Patients With Asymptomatic Persistent Atrial Fibrillation.

BACKGROUND: Efficacy of catheter ablation (CA) of asymptomatic persistent atrial fibrillation (AF) remains unclear. We assessed the quality of life (QOL), exercise performance (EP), and plasma B-type natriuretic peptide (BNP) levels following CA in patients with asymptomatic AF.Methods and Results:We enrolled 34 patients with asymptomatic persistent AF. QOL, was assessed by 2 questionnaires: the Short Form-36 (SF-36) and a QOL questionnaire specific for AF (AFQLQ). The QOL, EP, and plasma BNP level were examined before and 6 months after CA. In the SF-36 survey 5 of 8 components and all 3 subsets of the AFQLQ significantly improved in the patients without recurrences (30 patients, 88%), but there were no differences in those with recurrences. In patients without recurrences, there was an increase in the metabolic equivalents of task (10.2±2.3 vs. 11.6±2.3 METs, P<0.0001), duration of maximal exercise (476±144 vs. 605±143 s, P<0.0001), and plasma BNP decrease (146.6±124.3 vs. 33.8±35.6 pg/dL, P<0.0001), with a linear correlation in the increased duration of exercise and plasma BNP decrease (R=0.620, P<0.0001). CONCLUSIONS: Maintenance of sinus rhythm after successful CA improved the QOL, EP, and plasma BNP level in patients with asymptomatic persistent AF. CA may be primarily applicable in such patients with previously unrecognized impairment in their QOL and EP.

The Efficacy of Isochronal 3D Mapping-Based Ablation of Ventricular Arrhythmia.

Treatment of ventricular arrhythmias (VAs) commonly involves ablating sites showing electrograms with the earliest activity relative to the VA, but there is no threshold value for prematurity guaranteeing success. Ablation of sites with great prematurity can still result in failure.We hypothesized that isochronal map area (ISCA), derived from isochrones indicating electrogram prematurity, could help identify ablation targets in VA patients, as well as predict outcome. Specifically, we hypothesized that smaller ICSA for a given prematurity value would indicate a shallower arrhythmogenic focus leading to a higher likelihood of successful ablation.We studied ICSA in 29 patients (12 males, 57 [17-65] years old) undergoing VA ablation. The VAs originated from the right and left ventricles in 11 and 18 patients, respectively. The earliest activation site of the VAs, ECG morphology of sinus beats and premature ventricular complexes (PVCs), and ISCA of activation preceding PVCs were evaluated.RF ablation at the site showing earliest prematurity resulted in VA elimination in 21 patients (success group). The 5-ms ISCA was smaller in the success group than in the failure group (0.2 [0.1-0.6] versus 1.0 [0.8-1.5] cm2, respectively; P < 0.01). No significant difference was noted in prematurity itself (36 [30-45] versus 30 [29-33] ms, respectively; P = 0.07). The cut-off value of the 5 ms ISCA for successful RF ablation was 0.7 cm2 with 87.5% sensitivity and 85.6% specificity.Isochrones of activity preceding PVCs appear to contain information beyond prematurity values and may help dictate suitable areas for successful ablation of VAs.

A case of an atrial tachycardia originating from an occluded coronary sinus ostium with a persistent left superior vena cava.

We present a case of a 37-year-old female who complained of frequent palpitations caused by an atrial tachycardia and atrial premature contractions. Angiography revealed that the coronary sinus was occluded at the ostium and connected to a persistent left superior vena cava. An electrophysiological study and three-dimensional mapping revealed that the origin of the atrial tachycardia and atrial premature contractions was at the coronary sinus ostium in the right atrium. After repeat applications of radiofrequency energy at that site, no further atrial tachycardia or atrial premature contractions were induced by atrial burst pacing. To the best of our knowledge, this is the first report of an atrial tachycardia originating from an occluded coronary sinus ostium.

Impact of a formula combining local impedance and conventional parameters on lesion size prediction.

BACKGROUND: Although ablation energy (AE) and force-time integral (FTI) are well-known active predictors of lesion characteristics, these parameters do not reflect passive tissue reactions during ablation, which may instead be represented by drops in local impedance (LI). This study aimed to investigate if additional LI data improves predicting lesion characteristics and steam pops. METHODS: RF applications at a range of powers (30 W, 40 W, and 50 W), contact forces (8 g, 15 g, 25 g, and 35 g), and durations (10-180 s) using perpendicular/parallel catheter orientations were performed in excised porcine hearts (N = 30). The correlation between AE, FTI, and lesion characteristics was examined, and the impact of LI (%LI drop (%LID) defined by the ΔLI divided by the initial LI) was additionally assessed. RESULTS: Three hundred seventy-five lesions without steam pops were examined. Ablation energy (W × s) and FTI (g × s) showed a positive correlation with lesion depth (ρ = 0.824:P < 0.0001 and ρ = 0.708:P < 0.0001), surface area (ρ = 0.507:P < 0.0001 and ρ = 0.562:P < 0.0001), and volume (ρ = 0.807:P < 0.0001 and ρ = 0.685:P < 0.0001). %LID also showed a positive correlation individually with lesion depth (ρ = 0.643:P < 0.0001), surface area (ρ = 0.547:P < 0.0001), and volume (ρ = 0.733:P < 0.0001). However, the combined indices of AE × %LID (AE multiplied by %LID) and FTI × %LID (FTI multiplied by %LID) provided significantly stronger correlation with lesion depth (ρ = 0.834:P < 0.0001 and ρ = 0.809:P < 0.0001), surface area (ρ = 0.529:P < 0.0001 and ρ = 0.656:P < 0.0001), and volume (ρ = 0.864:P < 0.0001 and ρ = 0.838:P < 0.0001). This tendency was observed regardless of the catheter placement (parallel/perpendicular). AE (P = 0.02) and %LID (P = 0.002) independently remained as significant predictors to predict steam pops (N = 27). However, the AE × %LID did not increase the predictive power of steam pops compared to the AE alone. CONCLUSION: LI, when combined with conventional parameters (AE and FTI), may provide stronger correlation with lesion characteristics.

Lower common pathway location detected by cryoablation of atrioventricular nodal reentrant tachycardia of the common variety.

As different from radiofrequency current energy, cryofreezing energy is able to provide reversible effects on cardiac tissue, called "cryomapping," which enables us to predict the effects of a subsequent application of ablative energy. Cryomapping is able to delineate the anatomical location of the lower common pathway of atrioventricular nodal reentrant tachycardia.

Propensity-matched comparison of cryoballoon and radiofrequency ablation for atrial fibrillation in elderly patients.

BACKGROUND: Pulmonary vein isolation (PVI) with a cryoballoon (CB) is an effective treatment for atrial fibrillation (AF). The efficacy of CB PVI for elderly patients with AF remains unclear. OBJECTIVE: We aimed to analyze the clinical outcomes of CB ablation compared with radiofrequency (RF) ablation in elderly patients with AF. METHODS: This was a single-center retrospective study of 305 patients older than 75 years with paroxysmal and persistent AF who underwent PVI between January 2012 and August 2017. Patients were matched according to propensity scores in a logistic regression model. The end point of this study was AF/atrial tachycardia recurrence at 12-month follow-up. RESULTS: In total, 198 patients (99 matched pairs) were analyzed. The ratio of paroxysmal AF was 83%, and the mean age was 78 ± 2 years. The mean procedure time was significantly lower in the CB group (134 ± 62 minutes vs 190 ± 51 minutes; P < .001). There was no significant difference between the groups in terms of success rate at 12 months after the procedure (CB 80.5% vs RF 79.4%; P = .72) or incidence of complications (CB 12% vs RF 16%; P = .80). Kaplan-Meier estimates revealed no significant difference between clinical outcomes after PVI with a CB or RF for elderly patients with non-pulmonary vein foci that were all successfully ablated (CB 68.8% vs RF 68.4% at 12 months; P = .835). CONCLUSION: The efficacy of PVI with a CB might be comparable to that of PVI with RF in AF patients older than 75 years and involve a shorter procedure time.

High defibrillation threshold with a subcutaneous implantable cardiac defibrillator due to the lead having been positioned in the fat layer.

A 46-year-old female with a body mass index of 38.9 kg/m2 and no organic heart disease underwent a subcutaneous implantable cardioverter-defibrillator implantation for secondary prevention of sudden cardiac death in the setting of idiopathic ventricular fibrillation. Defibrillation threshold (DFT) testing during implantation detected high shock impedance and high DFT. Fluoroscopy revealed subcoil fat between the lead and the sternum, which we suspected was the reason for the high shock impedance and high DFT. We repositioned the lead to a site just above the sternum and the shock impedance and DFT improved to within the respective normal ranges.

Efficacy of Catheter Ablation and Concomitant Antiarrhythmic Drugs on the Reduction of the Arrhythmia Burden in Patients with Long-Standing Persistent Atrial Fibrillation.

BACKGROUND: Little is known about the long-term outcome and recurrent form recurrence after catheter ablation of atrial fibrillation (AF) in patients with long-standing persistent AF. METHODS: Two hundred thirty-six patients with persistent AF (193 men; age, 61.5±10.7 years) were enrolled, and were classified according to the duration of AF: AF duration of <1 year (group A, n=99), between 1 to 5 years (group B, n=101), and ≥5 years (group C, n=36). The long-term recurrence rate and recurrent form were compared among the groups. RESULTS: During a median follow-up of 3.7 years, the recurrence rate was significantly worse in group C after the index and multiple procedures (Log-Rank, both for a P<0.001 in comparison to group A). In the multivariate analysis, the duration was an independent predictor of an arrhythmia recurrence (HR, 1.206; 95%CI, 1.053 to 1.381; P=0.007). Recurrent AF became permanent in 8 patients (3.4%), which was not associated with a difference in the groups (Log-rank, P=0.055), while antiarrhythmic drugs (AADs) were continued in 70% of the recurrent patients. CONCLUSION: Despite a high AF recurrence rate in the patients with an AF duration of ≥5 years, the majority of the patients with recurrence who continued on AADs had a paroxysmal form of AF. Catheter ablation and concomitant AADs may be effective in reducing the AF burden in such patients with an advanced AF disease stage.

Efficacy and safety of uninterrupted rivaroxaban taken preoperatively for radiofrequency catheter ablation of atrial fibrillation compared to uninterrupted warfarin.

PURPOSE: Data on uninterrupted rivaroxaban taken preoperatively for radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) is limited. The aim was to evaluate safety and efficacy of rivaroxaban taken in the morning for AF ablation, especially with regard to asymptomatic cerebral emboli (ACE) and anticoagulation parameters. METHODS: We prospectively evaluated 147 consecutive patients who underwent RFCA (mean age 66, 110 patients with paroxysmal AF), 76 of whom were on rivaroxaban, 71 on warfarin. The drugs were continued throughout the periprocedural period, including the morning of RFCA. Heparin infusion was maintained during RFCA to achieve an activated clotting time (ACT) of >300 s. RESULTS: There were no significant differences in basic patient characteristics and ablation procedure between the two groups. ACT during the procedure correlated significantly with prothrombin time and international normalized ratio in each group (correlation coefficient 0.799 in rivaroxaban, 0.705 in warfarin, p < 0.01). D-dimer level was more elevated after RFCA in the warfarin group than in the rivaroxaban group (warfarin 0.37 ± 0.28 to 0.67 ± 0.81, rivaroxaban 0.41 ± 0.33 to 0.51 ± 0.25, p = 0.02). One major bleeding event (1.3%), a cardiac tamponade, was observed in the warfarin group. No symptomatic thromboembolic complications were observed in either group. Two patients (3%) in each group had minor bleeding, specifically, groin hematoma. Postprocedural MRI indicated ACE in 5/46 (11%) patients in the rivaroxaban group and 4/39 (10%) in the warfarin group (p = 0.99). CONCLUSIONS: Uninterrupted rivaroxaban taken preoperatively for AF ablation is clinically effective and safe. Its ACE profile is similar to warfarin. ACT is sufficient for monitoring anticoagulation.