Treatment of atrial fibrillation with second-generation cryoballoon followed by contact-sensing radiofrequency catheter ablation for arrhythmia recurrences-results of a 5-year follow-up.

INTRODUCTION: The aim of this study was to report the long-term follow-up results of cryoballoon (CB) ablation in patients with atrial fibrillation. METHODS: All consecutive patients who underwent second-generation CB ablation from February 2015 to December 2017 were included in our study. In all procedures, we used a 28-mm CB placed via a single transseptal puncture guided by intracardiac ultrasound. A 20-mm octapolar intraluminal circular catheter was used for intracardiac recordings. A single 180-s freeze strategy was employed. Repeated procedures were performed with a 3D mapping system and radiofrequency catheters. RESULTS: A total of 126 patients (69.8% male, mean age 57 ± 11 years), of which 77.0% had paroxysmal atrial fibrillation (PAF), were included in the study. After a 5-year period, 52.4% of patients were in sinus rhythm without AF recurrence, off antiarrhythmic drugs. A total of 61.9% of patients were free of AF recurrence when redo PVI procedures were performed. When accounting for redo pulmonary vein isolation and antiarrhythmic drugs, a total of 73.8% of the patients were without AF recurrence in long-term follow-up. The patients who underwent redo pulmonary vein isolation procedures had statistically significant lower rates of AF recurrence (p = 0.006). In patients with PAF, long-term success rates improved from 62.9 to 79.4% for patients who underwent the redo procedure (p = 0.020). In patients with persistent atrial fibrillation (PersAF), success rates went up from 41.4 to 55.1% for patients with single or repeated PVI procedure (p = 0.071). In the whole cohort, a total of 3 (2.4%) procedure-related major complications occurred which included persistent PNP, arterial pseudoaneurysm, and arteriovenous fistula. CONCLUSION: Our data suggest a favorable long-term safety and efficacy profile of second-generation CB ablation. In the mixed paroxysmal and persistent population, up to 73.8% of patients remained free of AF recurrence in the 5-year follow-up, when accounting for redo procedures and AADs. Only 2.4% of patients experienced major complications of the ablation procedure, none with permanent sequelae.

Feasibility and safety of reprocessing of intracardiac echocardiography catheters for electrophysiology procedures - a large single center experience.

PURPOSE: Intra-cardiac echocardiography (ICE) has become an important tool for catheter ablation. Adoption of ICE imaging is still limited because of its prohibitively high cost. Our aim was to study the safety and feasibility of ICE catheters reprocessing and its environmental and financial impact. METHODS: This was a single center retrospective analysis of all consecutive electrophysiology procedures in which ICE catheters were used from 2015 to 2022. In total, 1128 patients were studied (70.6% male, mean age was 57.9 ± 13.2 years). The majority of procedures were related to atrial fibrillation ablation (84.6%). RESULTS: For the whole cohort, 57 new ICE catheters were used. Consequently one catheter could be used for 19.8 procedures. New catheters were only used when the image obtained by reused probes was not satisfactory. There were no cases of ICE probe steering mechanism malfunction, no procedure related infections and no allergic reactions that could be attributed to the resterilization process. In total, there was 8.6% of complications not related to ICE imaging. Financially, ICE probe reprocessing resulted with 90% cost reduction (> 2 millions of Euros savings for the studied period) and 95% waste reduction (639.5 kg less, mostly non degradable waste was produced). CONCLUSION: Our data suggests that ICE catheter reprocessing is feasible and safe. It seems that risk of infection is not increased. Significant economic and environmental savings could be achieved by ICE catheters reprocessing. Furthermore, ICE reprocessing could allow more extensive ICE usage resulting in safer procedures with a potential reduction of serious complications.

Radiation dose reduction in the setting of cryoballoon ablation for atrial fibrillation: the value of optimized fluoroscopy settings and intracardiac echocardiography.

Cryoballoon (CB) has proven to be very effective in the percutaneous treatment of atrial fibrillation (AF). CB ablation is still hampered by X-ray exposure and the doses applied are consistently higher if compared to radiofrequency ablation. All patients who underwent CB ablation between 2015 and 2020 were analysed. Intracardiac echography was consistently used for transeptal puncture. To demonstrate the differences in radiation exposure 3 groups of 50 consecutive patients were selected. In the first group (G1) 3D rotational angiography (3DRA) was used as an intraprocedural imaging method. In the second group (G2), traditional X-ray imaging was used and frame rates both for fluoro and cine modes of diascopy were lowered. In the third group (G3) only 2-3 frames per second were used, cine mode was abandoned and the grid was removed from the X-ray detector. A total of 150 patients were included (76% males, mean age 57.3 ± 11.5 years). A dramatic reduction of radiation dose was obtained from 9585 ± 5610 µGy/m2 in G1 to 2469 ± 2002 µGy/m2 in G2 and finally 227.1 ± 360 µGy/m2 in G3 (p < 0.0001). There was also a significant decrease of procedural and fluoroscopy times. No difference in major complications and midterm outcomes was found between the groups. By following a few relatively simple steps (omitting the pre-procedural imaging, removing grid from the X-ray detector and using very low frame rates) CB ablation could be performed with ultralow radiation exposure without compromising the safety of efficacy of the procedure.

Intra-procedural three-dimensional rotational angiography in cryoballoon ablation for atrial fibrillation.

Cryoballoon (CB) is an established technology for atrial fibrillation (AF) ablation and is usually performed using solely fluoroscopy. We aimed to study the feasibility of three-dimensional rotational angiography (3DRA) as intra-procedural imaging in CB ablation. Analyzed data were retrospectively collected from patients that underwent second generation CB ablation from February 2015 to August 2017. We studied 68 consecutive patients that received 3DRA (3DRA group). Sixty-six patients who received conventional X-ray imaging served as a control group. 3DRA was performed via an introducer placed in the left atrium. Angiographic images were segmented and fused with live fluoroscopy to guide the ablation. We have analyzed 134 CB patients (73.8% male, 56.9 ± 11.4 years). Paroxysmal AF was present in 77.6% of patients. 3DRA was successfully performed in all 3DRA group patients. The mean procedure time was significantly shorter in the control group (82.4 ± 26.3 min) than in the 3DRA group (121.1 ± 21.4 min) (p < 0.0001). Total radiation dose (419.3 ± 317.9 vs 998.3 ± 673 mGy, p < 0.0001) and contrast administration (83.2 ± 22.3 mL vs 191.6 ± 33.4 mL, p < 0.0001) were significantly lower in control group. There was no significant difference in 2-year success rate, 35.2% of patients had AF recurrence in the 3DRA group and 30.3% in the control group (p = 0.584). Major complications occurred in 2.9% and 1.5% of patients in 3DRA group and control group, respectively (p = 1.000). 3DRA is a feasible method of intra-procedural imaging to guide CB ablation. However, it prolongs procedure time, increases radiation dose and contrast administration with no significant effect on procedure outcomes and complication rates.

Use of figure of eight suture for groin closure with no heparin reversal in patients undergoing cryoballoon ablation for atrial fibrillation.

PURPOSE: We aimed to demonstrate the feasibility of figure of eight (FoE) suture for groin access closure in cryoballoon (CB) ablation and its impact on the lab workflow. METHODS: We retrospectively analyzed all patients who underwent CB ablation in our institution from June 2018. From June 2019, we have been consistently using FoE suture for hemostasis (FoE+ group), and before that conventional manual compression was utilized (FoE- group). Ablations were performed under uninterrupted oral anticoagulant strategy. Both femoral veins were punctured, and a single introducer was placed in each vein. In the FoE- group, after ablation, protamine was administered, and manual compression was applied. In the FoE+ group, the suture was placed in both groins without protamine administration and manual compression. All patients were in decubitus position until the next morning. RESULTS: A total of 190 consecutive patients (73.2% male, 59.7 ± 11.0 years old) were evaluated, 90 being in the FoE+ group. There was no difference in the mean procedure duration between two groups (72.7 ± 23.1 min vs 73.7 ± 27.1 min, p = 0.784). However, the total lab time was significantly longer in FoE- group (132.9 ± 35.3 min vs 109.9 ± 32.6 min, p < 0.0001). There was no difference in complication rates. No major vascular complications were found in our cohort. CONCLUSIONS: Utilization of FoE sutures for hemostasis seems to be a safe and effective after cryoballoon ablation. It abolishes the need for protamine administration which can cause serious adverse events. As manual compression is unrequired, EP lab workflow improves due to significantly shortened total lab time per patient.

Improved real-time recordings using the fourth-generation cryoballoon technology-detection of dual fascicle electrograms.

BACKGROUND: We aimed to analyze the rate of visualization of real-time (RT) recordings and dual fascicle electrograms in our first series of patients treated with the fourth-generation cryoballoon (CB) device. METHODS: All consecutive patients who underwent CB ablation using the fourth-generation technology were included in the analysis. In all procedures, we used a 28-mm CB placed via a single transseptal puncture guided by intracardiac ultrasound. A 20-mm octapolar intraluminal circular catheter was used for intracardiac recordings. A single 180-s freeze strategy was employed. RESULTS: A total of 129 patients (72.9% male, mean age 60.1 ± 10.9 years) were enrolled in the study. RT recordings were detected in 445 (86.2%) pulmonary veins (PVs). Specifically, RT recordings were visualized in 115 left superior PVs (89.2%), 107 left inferior PVs (82.9%), 118 right superior PVs (91.4%), and 105 right inferior PVs (81.3%). Dual fascicle electrograms could be observed only in patients in sinus rhythm, in 23 of 396 PVs (5.8%). They were most commonly observed in the left superior PV (8.1%), somewhat less in both inferior veins (6.1%), while this phenomenon was least frequent in the right superior PV (3.0%). CONCLUSIONS: By using the fourth-generation CB, we report a specific pattern of isolation represented by a sequential isolation of two apparently distinct PV fascicles during a single CB freeze delivery. This phenomenon occurred in 5.8% of PV ablations. Of note, the rate of visualization of RT isolation with this novel CB was very high and could be documented in 86.2% of PVs.

Learning curves in atrial fibrillation ablation - A comparison between second generation cryoballoon and contact force sensing radiofrequency catheters.

OBJECTIVE: To examine the learning curves of atrial fibrillation (AF) ablation comparing the cryoballoon (CB) and radiofrequency (RF) catheters. METHODS: We performed a retrospective data analysis from the initiation of AF ablation program in our center. For CB ablation, a second generation 28 mm balloon was utilized and for RF ablation. RESULTS: A total of 100 consecutive patients (50 in each group) have been enrolled in the study (male 74%, mean age 58.9 ± 10 years, paroxysmal AF 85%). The mean procedure time was shorter for CB (116.6 ± 39.8 min) than RF group (191.8 ± 101.1 min) (p < 0.001). There was no difference in the mean fluoroscopy time, 24.2 ± 10.6 min in RF and 22.4 ± 11.7 min in CB group, (p = 0.422). Seven major complications occurred during the study; 5 in RF group (10%) and 2 in CB group (4%) (p = 0.436). After the mean follow up of 14.5 ± 2.4 months, 15 patients in RF group (30%) and 11 in CB group (26%) experienced AF recurrences (P = 0.300). CONCLUSION: When starting a new AF ablation program, our results suggest that CB significantly shortens procedure while fluoroscopy time and clinical outcomes are comparable to RF ablation.