Luca Ottaviano

Pulmonary vein isolation as index procedure for persistent atrial fibrillation: One-year clinical outcome after ablation using the second-generation cryoballoon

BACKGROUND No data are available about the clinical outcome of pulmonary vein isolation (PVI) as an index procedure for persistent atrial fibrillation (PersAF) ablation using the second-generation cryoballoon (CB-Adv). OBJECTIVE The purpose of this study was to assess the 1-year efficacy of PVI as an index procedure for PersAF ablation using the novel CB-Adv. METHODS Sixty-three consecutive patients (45 male [71.4%], mean age 62.7 ± 9.7 years) with drug-refractory PersAF undergoing PVI using the novel CB-Adv were enrolled. Follow-up was based on outpatient clinic visits including Holter ECGs. Recurrence of atrial tachyarrhythmias (ATas) was defined as a symptomatic or documented episode >30 seconds. RESULTS A total of 247 PVs were identified and successfully isolated with a mean of 1.7 ± 0.4 freezes. Mean procedural and fluoroscopy times were 87.1 ± 38.2 minutes and 14.9 ± 6.1 minutes, respectively. Among 26 of 63 patients (41.3%) presenting with AF at the beginning of the procedure, 7 of 26 (26.9%) converted to sinus rhythm during ablation. Phrenic nerve palsy occurred in 4 of 63 patients (6.3%). At 1-year follow-up, after a 3-month blanking period (BP), 38 of 63 patients (60.3%) were in sinus rhythm. Because of ATa recurrences, 9 patients underwent a second procedure with radiofrequency ablation showing a pulmonary vein reconnection in 4 right-sided PVs (44.4%) and 3 left-sided PVs (33.3%). Multivariate analysis demonstrated that PersAF duration (P = .01) and relapses during BP (P = .04) were independent predictors of AT recurrences. CONCLUSION At 1-year follow-up, freedom from ATas following PersAF ablation with the novel CB-Adv is 60%. Phrenic nerve palsy is the most common complication. PersAF duration and relapses during the BP appear to be significant predictors of arrhythmic recurrences.

Cryoballoon ablation for atrial fibrillation guided by real-time three-dimensional transoesophageal echocardiography: a feasibility study

AIMS Cryoballoon ablation (CBA; Arctic Front, Medtronic) has proven very effective in achieving pulmonary vein isolation. Real-time three-dimensional transoesophageal echocardiography (RT 3D TEE) is a novel technology, which permits detailed visualization of cardiac structures in a 3D perspective. The aim of the present study was to assess the feasibility, advantages, and safety of RT 3D TEE in guiding CBA in a series of patients affected by paroxysmal atrial fibrillation. METHODS AND RESULTS Forty-five patients (34 males, mean age: 63 ± 12 years) underwent CBA guided by 3D TEE. A total of 190 veins could be documented by TEE. Real-time three-dimensional transoesophageal echocardiography successfully guided the operator to position the CB in the pulmonary vein (PV) ostium and obtain complete occlusion in all 190 (100%) veins. Transoesophageal echocardiography identified leakages in 25 (13%) veins led to successful elimination of PV-left atrium (LA) backflow by guiding correct balloon repositioning. In four (2%) veins, this imaging tool led to perform successful pull-down manoeuvres. After a mean 2.6 ± 1.4 applications, isolation could be documented in 190 (100%) PVs. Median procedural and fluoroscopy times were 145 and 24 min. During a median follow-up of 278 days, 37 (82%) patients did not experience atrial fibrillation recurrence following a 3-month blanking period. CONCLUSION Cryoballoon ablation is safe and feasible under RT 3D TEE guidance. This imaging tool permits perfect visualization of all PV ostia and neighbouring LA structures. Most importantly, it proved very efficient in guiding the operator to achieve complete occlusion and successful isolation in all veins.

Ablating the ventricular insertion of atrio-fascicular Mahaim fiber: what selection criteria should we use?

We reported a patient who underwent RF ablation of the distal insertion of an atrio-fascicular accessory pathway with decremental properties because of inability to map a suitable potential alongside the tricuspid annulus. Small, discrete potentials resembling those of purkinje fiber were found at right ventricular apex, all these potentials showed early activation during tachycardia preceding the QRS onset of various degrees. Pace mapping helped to localize the presumed main distal insertion of the atrio-fascicular AP in a region where a damage of the His-purkinje system may ensue. This case report describes catheter ablation of an atriofascicular accessory pathway by targeting its distal (ventricular) insertion site.

A particular case of transient ST elevation during cryoballoon ablation of atrial fibrillation

Introduction The cryoballoon (CB) technology nowadays represents a valid alternative to the radiofrequency for pulmonary vein (PV) isolation. Transient ST elevation has been reported as a rare adverse event occurring during atrial fibrillation (AF) ablation and is mostly related to air embolism during contrast injection. However, the present case describes the occurrence of ST elevation during CB ablation secondary to the proximity of a venous bypass graft for the distal right coronary artery to the ostium of left inferior pulmonary vein (LIPV).

In-Hospital Cardiac Arrest: Are We Well Enough Equipped and Prepared to Face It?

Sudden death is a real concern for nowadays medicine, especially as it can occur in people with no signs of disease at all. It can be the first symptom of an underlying problem. It may be defined as an unexpected event occurring with no warning signs, within less than an hour, in a person with a known but stable cardiac problem, or in a person with an unknown but pre-existing problem. Often a cardiac problem is the substrate for cardiac arrest (Table 1), but many other diseases can be the underlying cause of sudden death, which in 75% of cases is due to ventricular fibrillation or tachycardia, in 20% to brad- yarrhythmia, and in 5% atrioventricular dissociation [1, 2]. In Italy it strikes more than 60 000 people per year, with a 10% overall mortality, 20% of which is made up of people with no previous signs of disease at all [1].

Electromagnetic Interference in Biventricular and/or ICD Paced Patients

The potential risk of interaction between electronic systems and implantable cardioverter-defibrillators (ICDs) is well documented and frequently reported on by the scientific press [1-4]. When an electronic medical device is exposed to radiofrequency (RF) signals by electronic systems, the RF energy (Table 1) is absorbed by the electronic circuitry and other components, and functioning may be altered. In a technologically advanced world, radiation from electronic system is omnipresent at home, work, and other everyday environments (Table 2). It is spread by different modes such as electrical leads or cables, electrostatic induction, electromagnetic radiation, intentional transmitters (radar, radio, TV and satellite transmissions, mobile telecommunication systems, scientific equipments), and unintentional transmitters (induction heaters, electrical equipment, car ignition systems, diathermy generators), and constitutes the main source of disturbances to active medical devices equipped with an electrical circuit prone to detect them.