Reduction of Iatrogenic Atrial Septal Defects with an Anterior and Inferior Transseptal Puncture Site when Operating the Cryoballoon Ablation Catheter.

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical transseptal puncture site is the fossa ovalis (FO) - the atrial septum's thinnest section. A potentially beneficial transseptal site, for the cryoballoon, is near the inferior limbus (IL). This study examines an alternative transseptal site near the IL, which may decrease the frequency of acute iatrogenic atrial septal defect (IASD). Also, the study evaluates the acute pulmonary vein isolation (PVI) success rate utilizing the IL location. 200 patients were evaluated by retrospective chart review for acute PVI success rate with an IL transseptal site. An additional 128 IL transseptal patients were compared to 45 FO transseptal patients by performing Doppler intracardiac echocardiography (ICE) post-ablation to assess transseptal flow after removal of the transseptal sheath. After sheath removal and by Doppler ICE imaging, 42 of 128 (33%) IL transseptal patients demonstrated acute transseptal flow, while 45 of 45 (100%) FO transseptal puncture patients had acute transseptal flow. The difference in acute transseptal flow detection between FO and IL sites was statistically significant (P <0.0001). Furthermore, 186 of 200 patients (with an IL transseptal puncture) did not need additional ablation(s) and had achieved an acute PVI by a "cryoballoon only" technique. An IL transseptal puncture site for cryoballoon AF ablations is an effective location to mediate PVI at all four PVs. Additionally, an IL transseptal location can lower the incidence of acute transseptal flow by Doppler ICE when compared to the FO. Potentially, the IL transseptal site may reduce later IASD complications post-cryoballoon procedures.

Prospective evaluation of the updated 2010 ACCF Cardiac CT Appropriate Use Criteria.

BACKGROUND: The cardiac CT Appropriate Use Criteria (AUC) were updated in 2010 to reflect technical advances, evolving expert consensus, and rapidly expanding clinical evidence. OBJECTIVE: We evaluated the effect of the AUC update on their clinical performance, including the completeness and distribution of appropriateness ratings and test outcomes among a consecutive series of patients referred for CT angiography (CTA). METHODS: The 2006 and 2010 criteria were prospectively applied at the point of service to a consecutive series of patients referred for CTA at a single center (n = 1216). Patient interview and review of available health records were used to determine the CTA indication. The proportions of patients within categories of appropriate (A), uncertain (U), inappropriate (I), and not covered were described and compared between the 2006 and 2010 criteria. RESULTS: The 2010 criteria significantly reduced the proportion of uncertain (30.5%-11.4%), inappropriate (16.0%-12.9%), and no covered (12.1%-4.7%; P < 0.001) indications, while increasing the proportion of appropriate tests from 41.4% to 71%. By the 2010 criteria, appropriate indications were more likely to lead to the detection of coronary artery stenosis (11.5% vs 6.7%; P = 0.03) and complete examinations (95.0% vs 90.8%; P = 0.03). CONCLUSION: The 2010 cardiac CT AUC update lead to more complete classification and to large shifts in the appropriateness ratings, underscoring the importance of ensuring the periodic revision of AUCs for evolving imaging technologies such that they perform optimally as quality measurement and reimbursement tools.