Cryoballoon ablation of paroxysmal atrial fibrillation within the dilated coronary sinus in a case of persistent left superior vena cava.

Trigger sources of paroxysmal atrial fibrillation (PAF) are not limited to a pulmonary vein origin and may be achievable by cardiac vascular structures like the coronary sinus (CS), the vena cava superior and in some rare cases by a persistent left superior vena cava (LSVC). Cryoballoon ablation has been shown to be effective in pulmonary vein isolation. We report an unusual case of using this technique in the dilated CS in case of a persistent LSVC. A 64 year old patient presented PAF recurrences after cryo pulmonary vein isolation 4 months before. A maintaining pulmonary vein isolation could be demonstrated by transseptal mapping. Further bi-atrial mapping localized repetitive atrial trigger activity in a dilated CS proceeding to a LSVC. A cryoballoon was deployed in the CS target area and during cryoablation the triggered activity suspended. Ablation side effects were excluded by coronary angiography. During a follow up time of 8 months the patient has remained free of PAF recurrences. The current report underlines the importance of a patient-tailored ablation approach. Cryothermic balloon technology may be more applicable in delicate cardiac structures by developing new anatomically adapted balloon shapes and sizes.

Automatic magnetic-guided electroanatomical mapping and remote-controlled ablation of atypical and typical atrial flutter.

UNLABELLED: Two patients with inconclusive surface electrocardiogram patterns underwent nonfluoroscopy automatic mapping and remote-controlled ablation of nonisthmus and isthmus-dependent right atrial flutter. METHODS AND RESULTS: A 0.08 magnetic vector force and a motor drive enable a complex steering of a new 8-mm magnet tip electrode. The navigation system performs atrial electroanatomical mapping fully automatically. Total procedural fluoroscopy time for ablation of nonisthmus-related atypical and isthmus-dependent flutter was 8.5 and 3.2 minutes, respectively. CONCLUSION: Automatic electroanatomical mapping offers a promising option to effectively guide the remote-controlled ablation of atrial reentry tachycardias and to reduce fluoroscopy time.

Magnetic-guided percutaneous coronary intervention enabled by two-dimensional guidewire steering and three-dimensional virtual angioscopy: initial experiences in daily clinical practice.

AIMS: Percutaneous coronary intervention (PCI) has been broadly established and often includes highly complex stenoses that require difficult navigation. The purpose of this study is to assess the feasibility of a new magnetic navigation system (MNS) to enable intracoronary guidewire deployment and PCI in daily clinical practice and to compare the 2D guidance to the virtual 3D angioscopy feature. METHODS AND RESULTS: We included 30 consecutive patients (pt) in whom 36 coronary arteries were PCI targets. Patients were randomized to guidewire steering by either 2D guidance or virtual 3D angioscopy (33%). In 31/36 (86%) interventions the MNS guidewire successfully passed the culprit stenosis and the procedure was accomplished by PCI. In 5/30 pt an MNS multivessel intervention was performed. Three of 5 unsuccessful procedures failed due to an unsuccessful recanalization of a subtotal chronic occlusion including 1 pt who required surgical intervention. In 2/36 procedures the magnetic guided intervention was performed effectively after prior conventional failure related to complex anatomy. The contrast medium amount needed to position the magnetic guidewire was 60 +/- 101 mL in 2D accomplished interventions vs. 14 +/- 15 mL in 3D procedures (p < 0.05). In 3 pt the MNS did not harm the implanted pacemaker or defibrillator system. CONCLUSION: Magnetic guided PCI is useful in selected patients. In our experience, success is less likely in evidence of a subtotal occlusion.

Prospective randomized comparison of closed cooled-tip versus 8-mm-tip catheters for radiofrequency ablation of typical atrial flutter.

INTRODUCTION: Cooled-tip and 8-mm-tip catheters have been found to be more effective than conventional 4-mm-tip catheters for radiofrequency (RF) ablation of common atrial flutter. The aim of this study was to compare the efficacy and safety of cooled-tip and 8-mm-tip catheters for flutter ablation in a randomized, prospective study. METHODS AND RESULTS: In 100 consecutive patients referred for ablation of common atrial flutter, cavotricuspid ablation was performed with a closed cooled-tip catheter (n = 50) or an 8-mm-tip ablation catheter (n = 50). RF current was applied for 60 to 120 seconds at powers of 40 to 50 W with the closed cooled-tip catheter and in a temperature-controlled mode (65 degrees C/70 W) with the 8-mm-tip catheter. The endpoint was achievement of a bidirectional isthmus conduction block. Cross-over was performed after 15 unsuccessful RF applications for each of the catheters. Complete bidirectional isthmus block was achieved in 99% of patients. Cross-over was performed in 11 patients after primary use of the cooled-tip catheter and in 9 patients after primary ablation with the 8-mm-tip catheter. No significant differences were found in the procedure parameters, such as overall RF applications (12.4 +/- 11.3 vs 12.9 +/- 8.6), ablation duration (42 +/- 43 min vs 39 +/- 27 min), and fluoroscopy time (17.0 +/- 18.7 min vs 15.7 +/- 10.7 min). In a mean follow-up of 8.3 months, 1 patient in the cooled-tip group and 3 patients in the 8-mm-tip group had recurrence of common atrial flutter. CONCLUSION: Use of the closed cooled-tip ablation catheter and the 8-mm-tip catheter have equal and high efficacy for RF ablation of common atrial flutter.