Rajin Choudhury

Second-generation cryoballoon ablation without the use of real-time recordings: A novel strategy based on a temperature-guided approach to ablation

BACKGROUND The achievement of -40°C within the first 60 seconds during cryoenergy applications has proven to independently predict durable pulmonary vein (PV) isolation in the setting of second-generation cryoballoon (CB-A; Medtronic, Minneapolis, MN) ablation. OBJECTIVE We sought to evaluate a strategy based on the attainment of the specific parameter of -40°C within the first 60 seconds during cryoenergy applications in the setting of CB-A ablation without the use of an inner lumen mapping catheter (Achieve, Medtronic) for the visualization of real-time recordings. METHODS A total of 52 patients having undergone CB ablation for paroxysmal atrial fibrillation (AF) between 1 February 2015 and 30 June 2015 who underwent a temperature-guided approach based on achieving -40°C within 60 seconds without real-time recordings (wire group) were compared with a cohort of 52 propensity score-matched patients having undergone CB ablation performed with an inner lumen mapping catheter (Achieve group). All PVs were checked for electrical isolation at the end of the procedure with a circular mapping catheter in the wire group. RESULTS Electrical isolation could be obtained in all patients in the Achieve group and in 99% of PVs in the wire group. Freedom from AF without antiarrhythmic drugs at a mean follow-up of 12.4 ± 3.0 months did not significantly differ between both groups (85% vs 88%, respectively; P = .56). CONCLUSION A temperature-guided approach based on achieving -40°C within 60 seconds is effective in producing PV isolation and affords freedom from AF at 12-month follow-up in 85% of patients affected by paroxysmal AF after a 3-month blanking period.

Efficacy and safety of the second generation cryoballoon ablation for the treatment of paroxysmal atrial fibrillation in patients over 75 years: a comparison with a younger cohort

Aims In this double centre, retrospective study, we aimed to analyse the 1-year efficacy and safety of cryoballoon ablation (CB-A) in patients older than 75 years compared with those younger than 75-years old. Methods and results Fifty-three consecutive patients aged 75 years or older with drug-resistant paroxysmal AF (PAF) who underwent pulmonary vein isolation (PVI) by the means of second generation CB-A, were compared with 106 patients aged <75 years. The mean age in the study group (>75 years) was 78.19 ± 2.7 years and 58.97 ± 8.5 in the control group. At 1-year follow-up the global success rate was 83.6% and did not significantly differ between older (10/53) and younger patients (16/106) (81.1 vs. 84.9%, P = 0.54). Transient phrenic nerve palsy was the most common complication which occurred in eight patients in the younger group and in three in the older group (7.5 vs. 5.7%, respectively, P = 0.66). Conclusions The results of our study showed that CB-A for the treatment of PAF is a feasible and safe procedure in elderly patients, with similar success and complications rates when compared with a younger population.

Role of Electrocardiographic Tpeak-Tend for the Prediction of Ventricular Arrhythmic Events in the Brugada Syndrome

Some previous studies have proposed the electrocardiographic Tpeak-Tend (TpTe) as a possible predictor of ventricular arrhythmic events in patients with Brugada syndrome (BrS). We sought to analyze the association between the parameters of repolarization dispersion (TpTe, TpTe/QT, TpTe dispersion, QTc, and QTd) and ventricular fibrillation/sudden cardiac death in a large cohort of patients with type 1 BrS. A total of 448 consecutive patients with BrS (men 61%, age 45 ± 16 years) with spontaneous (n = 96, 21%) or drug-induced (n = 352, 79%) type 1 electrocardiogram were retrospectively included. At the time of the diagnosis or during a mean follow-up of 93 ± 47 months (median 88 months), 43 patients (9%) documented ventricular arrhythmias. No significant difference was observed in TpTe, TpTe/QT, maximum TpTe, and TpTe dispersion between asymptomatic patients and those with syncope and malignant arrhythmias. TpTe/QT ratio did not also significantly differ between patients with ventricular fibrillation/sudden cardiac death and those asymptomatic ones. In conclusion, TpTe was not significantly prolonged in those patients with type 1 BrS presenting with unexplained syncope or malignant arrhythmic events during follow-up.

Long-term outcome of pulmonary vein isolation in patients with paroxysmal atrial fibrillation and Brugada syndrome

Aims The therapeutical management of atrial fibrillation (AF) in the setting of Brugada syndrome (BS) might be challenging as many antiarrhythmic drugs (AADs) with sodium channel blocking properties might lead to to the development of ventricular arrhythmias. This study sought to evaluate the clinical outcome in a consecutive series of patients with BS having undergone pulmonary vein (PV) isolation by means of radiofrequency (RF) or cryoballoon (CB) ablation and the efficacy of catheter ablation for preventing inappropriate interventions delivered by implantable cardioverter defibrillators (ICD) on a 3-year follow up. Methods and results Twenty-three consecutive patients with BS (13 males; mean age was 47 ± 18 years) having undergone PV isolation for drug-resistant paroxysmal AF were enrolled. Eleven patients (48%) had an ICD implanted of whom four had inappropriate shocks secondary to rapid AF. Over a mean follow-up period of 35.0 ± 25.4 months (median 36 months) the freedom from AF recurrence after the index PV isolation procedure was 74% without AADs. Patients with inappropriate ICD interventions for AF did not present futher ICD shocks after AF ablation. No major complications occurred. Conclusion Catheter ablation is a valid therapeutic choice for patients with BS and paroxysmal AF considering the high success rates, the limitations of the AADs and the safety of the procedure, and it should be taken into consideration especially in those patients presenting inappropriate ICD shocks due to rapid AF.

Impact of an additional right pulmonary vein on second-generation cryoballoon ablation for atrial fibrillation: a propensity matched score study

PurposeCryoballoon (CB) technology in the context of anatomical pulmonary vein (PV) variants might hypothetically hamper successful PV isolation (PVI). Our aim was to assess the impact of a right middle PV (RMPV) in the setting of second-generation cryoballoon (CB advance—CB-A), on procedural parameters and on mid-term follow-up.MethodsConsecutive patients with AF presenting RMPV (RMPV+) at the pre-procedural computed tomography who underwent PVI by CB-A were enrolled. Comparison with propensity score-matched patients without RMPV (RMPV−) was performed. Acute procedural parameters and clinical follow-up were assessed.ResultsA total of 240 patients (80 RMPV+) were included in the analysis. Twelve of 80 (15%) RMPV+ patients underwent a direct cryo-application in this variant and accomplished the isolation without phrenic nerve palsy, whereas in 25 of 80 (31%) RMPV+ patients, the RMPVs were not targeted directly nor indirectly (by co-occlusion during application at a major PV). At a median follow-up of 17.3 [interquartile range 11.3–26.5] months, there was no significant difference in AF-free survival between RMPV+ and RMPV− patients (78.8 vs 78.1%, P = 1.00), and the recurrence of atrial arrhythmias among patients with versus without an intentional or indirect cryo-application to the RMPV was not different (22 vs 20%, P = 1.00).ConclusionsMid-term outcome after CB-A ablation did not differ between RMPV+ and RMPV− patients. Within RMPV+ patients, outcome was similar between those with versus without a cryo-application (either direct or indirect) to the additional vein.

Continuous monitoring after second-generation cryoballoon ablation for paroxysmal atrial fibrillation in patients with cardiac implantable electronic devices

BACKGROUND The second-generation cryoballoon (CB) is effective in achieving pulmonary vein isolation. Continuous monitoring would eliminate any over- or underestimated freedom from atrial fibrillation (AF) postablation. OBJECTIVE The purpose of this study was to differentiate between arrhythmias occurring after cryoballoon ablation (CBA), detecting true AF in symptomatic patients and detecting silent subclinical AF. METHODS Between June 2012 and January 2015, 54 patients with a preexisting cardiac implantable electronic device (CIED) who had undergone CBA for paroxysmal atrial fibrillation (PAF) were included in our retrospective study. Regular CIED controls, physical examination, and ECG recordings were performed by an experienced cardiologist blinded to the ablation procedure. Data on any hospitalization during follow-up were gathered. Patients were encouraged to note all clinical symptoms during follow-up. RESULTS Continuous monitoring showed a success rate of 83.3% after 1 year and 75.93% after 3 years of follow-up. During the first year, 68% of episodes of palpitations after ablation were due to sinus tachycardia, nonsustained ventricular tachycardia, or supraventricular tachycardia. AF recurrence was detected in 15.6% of asymptomatic patients during follow-up. Total AF burden post-CBA had decreased to 0.64% ± 4.34% (P <.001) during long-term follow-up of 3.3 years. CONCLUSION Although this is a selected group of patients with a preexisting CIED, continuous monitoring showed freedom from AF in 83.3% of patients post-CBA after 1 year and 75.93% after 3 years of follow-up.

Clinical value of induction protocol after second generation cryoballoon ablation for paroxysmal atrial fibrillation

Aims The predictive value of induction studies after catheter ablation for atrial fibrillation (AF) is still debatable. To date, these studies have not been implemented in patients after cryoballoon (CB) ablation. Our aim was to analyse the clinical value of AF induction in patients treated by second generation CB for paroxysmal AF. Methods and results Seventy patients underwent at first an isoproterenol challenge after pulmonary vein (PV) isolation to assess AF induction and early PV reconnections (EPVR). Patients without EPVR were evaluated for premature atrial contraction (PAC) induction; atrial ectopy was considered frequent (PAC+) if >1/10 cycles or >6/min. After restitution of baseline heart rate, rapid atrial pacing (RAP) was performed on all patients. AF induction by isoproterenol occurred only in 3/70 (4%) patients of whom 2/3 (66%) patients with an EPVR of a triggering vein. In the 62 patients without EPVR, PAC+ occurred in 17 patients (27%). RAP could induce AF in 23/70 (33%) patients. At a mean follow-up of 13.5 months, there were 11/70 (16%) AF recurrences. There was no significant difference in the AF recurrence rate between RAP inducible vs. non-inducible patients (log-rank P = 0.33). A 41% recurrence rate (7/17 patients) was seen in the PAC+ group with significantly different AF-free survival for PAC+ vs. PAC- patients (log rank P < 0.0001). PAC+ was the only independent determinant to predict AF recurrence after multivariate analysis. Conclusion PAC occurrence in response to isoproterenol could predict AF recurrence after PV isolation by CB, while RAP showed no prognostic implication.

Second generation cryoballoon ablation for atrial fibrillation in young adults: midterm outcome in patients under 40 years of age

Aims Pulmonary vein isolation (PVI) has been demonstrated more effective in young patients, in which the substrate for atrial fibrillation (AF) is probably more confined to pulmonary vein potentials. The present study sought to focus on the midterm outcomes in patients under 40 years having undergone PVI with the Cryoballoon Advance because of drug resistant AF. Methods and results Between June 2012 and December 2015, 57 patients having undergone Cryoballoon ablation (CB-A) below 40 years of age for AF in our centre were retrospectively analysed and considered for our analysis. All patients underwent this procedure with the 28 mm Cryoballon Advance. All 227 veins were successfully isolated without the need for additional focal tip ablation. Median follow-up was 18 ±10 months. The freedom from AF after a blanking period of 3 months was 88% in our cohort of patients younger than 40 years old. The most frequent periprocedural complication was related to the groin puncture and occurred in 2 patients. After a single procedure, the only univariate predictor of clinical recurrence was the diagnosis of hypertrophic cardiomyopathy. Conclusion Young patients affected by AF can be effectively and safely treated with CB-A that grants freedom from AF in 88% of the patients at 18 months follow-up following a 3-month blanking period. All veins could be isolated with the large 28 mm Cryoballoon Advance only.

Ehlers-Danlos syndrome

We present a clinical case of a 63-year old Caucasian man with Ehlers-Danlos syndrome who was admitted with atrial fibrillation and arterial hypertension. We present this not as a cardiological case but instead address the key questions of differential diagnosis, diagnosis criteria, management and improving the patient’s quality of life.