Intracardiac echocardiography guided nonocclusive balloon cryothermal applications to achieve antral isolation during pu
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Intracardiac echocardiography guided nonocclusive balloon cryothermal applications to achieve antral isolation during pulmonary vein isolation Moussa Saleh 1 & Kristie M. Coleman 1 Stavros E. Mountantonakis 1
&
Aditi S. Vaishnav 1
&
Jamie Shein 1 & Parth Makker 1 & Nicholas Skipitaris 1 &
Received: 4 September 2020 / Accepted: 21 October 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Objective Ablation for atrial fibrillation (AF) requires electrical isolation of the pulmonary veins (PV) by wide-area circumferential PV antral isolation (PVAI). Cryoballoon ablation delivers cryoenergy circumferentially after occlusion of the PV by the cryoballoon; thus, it is likely that the level of isolation, determined by adequate balloon-tissue contact, depends on PV anatomy. We sought to examine the need for nonocclusive segmental cryoballoon ablation in achieving antral isolation, describe methods of accurate visualization of the cryoballoon using intracardiac echocardiography (ICE), and provide data on biophysical characteristics of an effective nonocclusive cryothermal lesion. Methods Forty consecutive patients undergoing catheter ablation with a second-generation 28-mm cryoballoon and electroanatomic mapping (EAM) were included. Balloon was visualized with ICE, and its location was registered in EAM using available technology (CARTOSOUND, Biosense Webster). Need for delivery of nonocclusive lesions was based on level of isolation post occlusive lesions. Results Nonocclusive lesions to PVAI was required in 26 of 40 patients (65%) or 46 out of 148 veins (31%). Left PVs > 19.4 ± 2.9 mm, right superior PV > 20.2 ± 4.7mm, funnel-shaped PVs, and right PVs not converging to a carina were more likely to require nonocclusive lesions to achieve an antral level of isolation. Projection of balloon contour on EAM using CARTOSOUND successfully predicted level of isolation by voltage mapping. Conclusion Nonocclusive cryoballoon applications are commonly required to achieve antral isolation. Use of ICE can be helpful in determining the accurate location of the balloon and in predicting the level of isolation by voltage map. Keywords Atrial fibrillation . Catheter ablation . Cryoablation . Cryoballoon . Pulmonary vein isolation . Posterior wall isolation
Abbreviations 3D EAM 3-dimensional electroanatomic map AF Atrial fibrillation CTA Computer tomography angiography LA Left atrium LIPV Left interior pulmonary vein LSPV Left superior pulmonary vein PVI Pulmonary vein isolation PVAI Pulmonary vein antral isolation PLAW Posterior left atrial wall * Kristie M. Coleman [email protected] 1
Department of Cardiac Electrophysiology, Northwell Health - Lenox Hill Heart and Lung, 100 East 77th Street 2 Lachman, New York, NY 10075, USA
RIPV RSPV
Right interior pulmonary vein Right superior pulmonary vein
1 Introduction The foundation of atrial fibrillation (AF) ablation procedures is electrical isolation of the pulmonary veins by circumferential ablation lesions [1–3]. Electrically pulmonary vein iso
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