Roland Richard Tilz

Long-Term Results of Catheter Ablation in Paroxysmal Atrial Fibrillation Lessons From a 5-Year Follow-Up

Background— Paroxysmal atrial fibrillation (AF) naturally progresses toward chronic AF at an estimated rate of 15% to 30% over a 1- to 3-year period. Pulmonary vein (PV) isolation is increasingly performed for the treatment of drug-refractory paroxysmal AF. The long-term data on clinical outcome after circumferential PV isolation are limited. Methods and Results— From 2003 to late 2004, 161 patients (121 men; age, 59.8±9.7 years) with symptomatic paroxysmal AF and normal left ventricular function underwent circumferential PV isolation guided by 3-dimensional mapping and double Lasso technique. Right-sided and left-sided continuous circular lesions encircling the ipsilateral PVs were placed with irrigated radiofrequency energy. The procedure end point was the absence of all PV spikes for at least 30 minutes after PV isolation verified by 2 Lasso catheters placed within the ipsilateral PVs. Sinus rhythm was present in 75 patients (46.6%) after the initial procedure during a median follow-up period of 4.8 years (0.33 to 5.5 years). A second procedure was performed in 66 and a third procedure in 12 patients. Recovered PV isolation conduction was observed in 62 of 66 patients (94.0%) during the second and in 8 of 12 patients (66.7%) during the third procedure. After a median of 1 (1 to 3) procedure, stable sinus rhythm was achieved in 128 of 161 patients (79.5%), whereas clinical improvement occurred in an additional 21 of 161 patients (13.0%) during a median follow-up of 4.6 years (0.33 to 5.5 years). Four patients in stable sinus rhythm died during follow-up. Progression toward chronic AF was observed in 4 patients (2.4%); however, only 2 patients reported symptoms. Conclusion— In patients with paroxysmal AF and normal left ventricular function, circumferential PV isolation results in stable sinus rhythm in the majority of patients, and low incidence of chronic AF was observed after ablation during up to 5 years of follow-up.

The ‘single big cryoballoon’ technique for acute pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a prospective observational single centre study

Aims Cryothermal energy (CTE) ablation via a balloon catheter (Arctic Front, Cryocath™) represents a novel technology for pulmonary vein isolation (PVI). However, balloon-based PVI approaches are associated with phrenic nerve palsy (PNP). We investigated whether ‘single big cryoballoon’-deployed CTE lesions can (i) achieve acute electrical PVI without left atrium (LA) imaging and (ii) avoid PNP in patients with paroxysmal atrial fibrillation (PAF). Methods and results After double transseptal punctures, one Lasso catheter and a big 28 mm cryoballoon catheter using a steerable sheath were inserted into the LA. PV angiography and ostial Lasso recordings from all PVs were obtained. Selective PV angiography was used to evaluate balloon to LA–PV junction contact. CTE ablation lasted 300 s, and the PN was paced during freezing at right-sided PVs. Twenty-seven patients (19 males, mean age: 56 ± 9 years, LA size: 42 ± 5 mm) with PAF (mean duration: 6.6 ± 5.7 years) were included. PVI was achieved in 97/99 PVs (98%). Median (Q1; Q3) procedural, balloon, and fluoroscopy times were 220 min (190; 245), 130 min (90; 170), and 50 min (42; 69), respectively. Three transient PNP occurred after distal PV ablations. No PV stenosis occurred. Total median (Q1; Q3) follow-up time was 271 days (147; 356), and 19 of 27 patients (70%) remained in sinus rhythm (3-month blanking period). Conclusion Using the single big cryoballoon technique, almost all PVs (98%) could be electrically isolated without LA imaging and may reduce the incidence of PNP as long as distal ablation inside the septal PVs is avoided.

Catheter Ablation of Long-Standing Persistent Atrial Fibrillation: 5-Year Outcomes of the Hamburg Sequential Ablation Strategy

OBJECTIVES This study describes the 5-year efficacy of catheter ablation for long-standing persistent atrial fibrillation (LS-AF). BACKGROUND Long-term outcome data after catheter ablation for LS-AF are limited. METHODS Long-term follow-up of 56 months (range 49 to 67 months) was performed in 202 patients (age 61 ± 9 years) who underwent the sequential ablation strategy for symptomatic LS-AF. Initial ablation strategy was circumferential pulmonary vein isolation (PVI). Additional ablation was performed only in acute PVI nonresponder, if direct current cardioversion failed after PVI. RESULTS After the first ablation procedure, sinus rhythm was documented in 41 of 202 (20.3%) patients. After multiple procedures, sinus rhythm was maintained in 91 of 202 (45.0%) patients, including 24 patients receiving antiarrhythmic drugs. In 105 patients, PVI was the sole ablative therapy, 49 (46.7%) of those patients remained in sinus rhythm during follow-up. Patients with a total AF duration of <2 years had a significantly higher ablation success rate than patients whose AF duration was >2 years (76.5% vs. 42.2%, respectively; p = 0.033). Persistent AF duration (hazard ratio: 1.09 [95% confidence interval: 1.04 to 1.13]; p < 0.001) independently predicted arrhythmia recurrences, and acute PVI responders had a reduced risk of relapse (hazard ratio: 0.57 [95% confidence interval: 0.41 to 0.78]; p < 0.001) after the first ablation. CONCLUSIONS During 5-year follow-up, single- and multiple ablation procedure success was 20% and 45%, respectively, for patients with LS-AF. For patients with a total AF duration of <2 years, the outcomes were favorable.

One-Year Clinical Outcome After Pulmonary Vein Isolation Using the Second-Generation 28-mm Cryoballoon

Background—The use of second-generation cryoballoon for pulmonary vein isolation in patients with paroxysmal atrial fibrillation has demonstrated encouraging acute and mid-term results. Long-term outcome data are not yet available. Methods and Results—Fifty patients (18 women; mean age, 61±11 years; mean left atrial diameter, 43±5 mm) with paroxysmal (36 of 50 patients; 72%) or short-standing (<3-month duration) persistent atrial fibrillation (14 of 50 patients; 28%) underwent cryoballoon-based pulmonary vein isolation. Freeze cycle duration was 240 seconds. After successful pulmonary vein isolation, a bonus freeze was applied. Follow-up was based on outpatient clinic visits at 3, 6, and 12 months including Holter-ECGs and telephonic interviews. Recurrence was defined as a symptomatic or documented arrhythmia episode >30 seconds excluding a 3-month blanking period. A total of 192 pulmonary veins were identified, and 191 of 192 (99%) pulmonary veins were successfully isolated. Phrenic nerve palsy occurred in 1 of 50 (2%) patients. Follow-up was available for 49 of 50 (98%) patients with a mean follow-up duration of 440±39 days. Thirty-nine of 49 (80%) patients remained in stable sinus rhythm. Of 8 of 10 patients with arrhythmia recurrence, a second procedure using radiofrequency ablation demonstrated left atrial to pulmonary vein reconduction. Conclusions—The use of second-generation 28-mm cryoballoon for pulmonary vein isolation results in an 80% 1-year success rate.

Catheter ablation for ventricular tachycardia after failed endocardial ablation: Epicardial substrate or inappropriate endocardial ablation?

BACKGROUND The substrate of myocardial ventricular tachycardia (VT) may involve the subepicardial myocardium. OBJECTIVE The purpose of this study was to assess the incidence of epicardial substrates in patients with a previously failed endocardial ablation attempt for VT as well as the safety and effectiveness of epicardial ablation. METHODS Using an electroanatomic mapping system, endocardial and epicardial maps were acquired. Irrigated radiofrequency current ablations of all inducible VTs were performed. RESULTS Between 2005 and 2009, 59 patients with or without structural heart disease underwent epicardial VT ablation. Pericardial access failed in 3 (5%) of these patients. Of the remaining 56 patients, an epicardial substrate was found in 41 (73%). Overall, acute success was achieved in 46 (78%) of 59 patients, with complete VT abolition in 27 (46%) and partial abolition in 19 (32%). Successful outcomes were the result of endocardial ablation only in 14 (24%) patients, epicardial ablation in 21 (36%), and endocardial/epicardial in 11 (19%). Ablation failed to prevent reinduction in 8 (13%) patients, and VTs were noninducible prior to ablation in 5 (8%). Two periprocedural deaths occurred, one after right ventricular perforation and one due to electromechanical dissociation. Hepatic bleeding occurred in two patients. Recurrence of any VT occurred in 27 (47%) of 57 surviving patients during median follow-up of 362 days (q1-q3; 180-468 days). Repeat epicardial mapping was not feasible due to adhesions in 3 (25%) of 12 patients. CONCLUSION In patients with a previously failed endocardial VT ablation, epicardial mapping reveals a VT substrate in nearly three fourths of all patients, and epicardial ablation is required for successful VT abolition in more than half of patients. However, life-threatening complications may occur. Repeat epicardial access was not possible in 25% due to local pericardial adhesions.

Increased incidence of esophageal thermal lesions using the second-generation 28-mm cryoballoon.

Background—Pulmonary vein isolation is an established treatment option for atrial fibrillation. To date, the incidence and quality of ablation-induced esophageal thermal lesions (ETLs) using the recently introduced second-generation cryoballoon (CB, ArcticFront Advance, Medtronic) is unknown. Methods and Results—In patients with drug-refractory paroxysmal atrial fibrillation or short-standing persistent atrial fibrillation, pulmonary vein (PV) isolation was performed using the second-generation CB. The endoluminal esophageal temperature was monitored via a temperature probe. After PV isolation, esophagogastroduodenoscopy (EGD) was performed to assess the incidence of ETLs. In 50 patients (18 women; age, 61±11 years; left atrial diameter, 43±5 mm), successful CB-based PV isolation was performed. Lowest median balloon temperature and esophageal temperature for the right superior PV were −51°C and 35.8°C, −47°C and 35°C for the right inferior PV, −51°C and 34.4°C for the left superior PV, −48°C and 34.6°C for the left inferior PV, and −54°C and 34.5°C for the left common PV, respectively. EGD performed 2±1 days post ablation demonstrated superficial thermal lesions and thermal ulcerations in 1 of 50 (2%) and 5 of 50 (10%) patients, respectively. In patients with ETLs, during ≥1 freeze cycle the endoluminal esophageal temperature measured <3.0°C. All thermal lesions were in the healing process on repeat EGD 4±2 days after initial endoscopy. Conclusions—Using the second-generation 28-mm CB, ETLs were detected in 6 of 50 (12%) patients. All ETLs were in the healing process on repeat EGD. An esophageal temperature safety cutoff may prove valuable in the prevention of ETLs and requires further evaluation.

Antithrombotic management in patients undergoing electrophysiological procedures: a European Heart Rhythm Association (EHRA) position document endorsed by the ESC Working Group Thrombosis, Heart Rhythm Society (HRS), and Asia Pacific Heart Rhythm Society (APHRS).

Since the advent of the non-vitamin K antagonist oral anticoagulant (NOAC) agents, which act as direct thrombin inhibitors or inhibitors of Factor Xa, clinicians are provided with valuable alternatives to vitamin K antagonists (VKAs). At the same time, electrophysiologists frequently perform more invasive procedures, increasingly involving the left chambers of the heart. Thus, they are constantly faced with the dilemma of balancing the risk for thromboembolic events and bleeding complications. These changes in the rapidly evolving field mandate an update of the European Heart Rhythm Association (EHRA) 2008 consensus document on this topic.1 The present document covers the antithrombotic management during different ablation procedures, implantation or exchange of cardiac implantable electronical devices (CIEDs), as well as the management of peri-interventional bleeding complications. The document is not a formal guideline and due to the lack of prospective randomized controlled trials (RCTs) for many of the clinical situations encountered, the recommendations are often ‘expert opinion’. The document strives to be practical for which reason we subdivided it in the three main topics: ablation procedure, CIED implantation or generator change, and issues of peri-interventional bleeding complications on concurrent antiplatelet therapy. For quick reference, every subchapter is followed by a short section on consensus recommendations. Many RCTs are ongoing in this field and it is hoped that this document will help to prompt further well-designed studies. ### Ablation of atrial fibrillation, left atrial arrhythmias and right sided atrial flutter In patients with symptomatic paroxysmal or even persistent atrial fibrillation (AF), catheter ablation is indicated when antiarrhythmic drugs have failed in controlling recurrences or even as a first-line therapy in selected patients.2–4 Patients with AF have an increased risk of thromboembolic events, which varies according to the presence of several risk factors.5,6 Apart from their intrinsic thromboembolic risks, ablation in these patients increases thromboembolic risk due to the introduction and manipulation …

Feasibility of circumferential pulmonary vein isolation using a novel endoscopic ablation system.

Background—Pulmonary vein isolation (PVI) is an established treatment option for patients with drug refractory paroxysmal atrial fibrillation. A novel compliant endoscopic ablation system housing a 980-nm-diode laser allows for discrete point-by-point ablation enabling a true circumferential ablation line design. We sought to determine the feasibility and safety of a circumferential ablation using endoscopic ablation system. Methods and Results—Thirty patients (17 female; mean age, 58±9 years) with a median paroxysmal atrial fibrillation history of 3 years (range, 1 to 17 years) were treated. PVI was achieved in 114 of 116 (98%) PVs (4 left common PVs), thereby achieving simultaneous PVI for separate ipsilateral PVs in 19 of 26 (73%) left PVs and 6 of 30 (20%) right PVs. The total procedure time was 250±62 minutes. Procedure time decreased from 310±59 to 220±37 minutes (P=0.0001) between the first 10 and the last 20 cases. Mean fluoroscopy time was 30±18 minutes. Twenty-seven patients underwent postoperative endoscopy showing no or minimal thermal lesions in the esophagus in 21 (78%) and 2 (7%), respectively. In 4 (15%) patients, an esophageal ulceration was found that healed without sequelae. One pericardial tamponade and 1 right-sided phrenic nerve palsy occurred. During a median follow-up of 168 days (113 to 203 days; q1-q3), 24 of 30 patients (80%) remained free of atrial fibrillation recurrence. Conclusions—Circumferential PVI using the novel compliant endoscopic ablation system was feasible in the majority of left PVs and minority of right PVs accompanied by a complication rate comparable to established approaches. To minimize the risk for thermal esophageal injury temperature monitoring is recommended.

Remote Robotic Navigation and Electroanatomical Mapping for Ablation of Atrial Fibrillation — Considerations for Navigation and Impact on Procedural Outcome

Background—Radiofrequency current ablation of atrial fibrillation (AF) requires high technical skills to achieve optimal catheter stability and is associated with an individually high x-ray exposure to both the patient and the operator. To facilitate catheter navigation and to reduce the operators x-ray burden, remote navigation (RN) systems have been developed. Considerations for navigation of a novel remote robotic navigation system in pulmonary vein isolation (PVI) procedures are reported. Methods and Results—In 65 patients with drug-refractory AF (43 paroxysmal, 22 persistent), complete circumferential PVI was performed using RN in conjunction with different electroanatomic mapping systems. Acute complete PVI using exclusively RN was achieved in 95%. The procedure time was 195±40 minutes. The operators x-ray exposure time was reduced by 6±4 minutes (35%) using RN. In 7 of 14 patients with persistent AF, conversion to sinus rhythm was achieved by radiofrequency current ablation. During a median follow-up period of 239 days (range, 184 to 314 days), 47 of 65 patients (73%) remained free of any documented atrial tachyarrhythmia recurrences after a single procedure. The relative proportion of patients remaining free of AF was 76% and 68% for paroxysmal and persistent AF, respectively. Conclusions—PVI using the novel RN system can be performed safely and effectively. One third of the operators fluoroscopy exposure time might be saved using RN. However, the questions of whether the overall fluoroscopy exposure is reduced by RN and whether RN improves PVI procedures needs to be assessed during a comparative trial between man and machine.Background— Radiofrequency current ablation of atrial fibrillation (AF) requires high technical skills to achieve optimal catheter stability and is associated with an individually high x-ray exposure to both the patient and the operator. To facilitate catheter navigation and to reduce the operator’s x-ray burden, remote navigation (RN) systems have been developed. Considerations for navigation of a novel remote robotic navigation system in pulmonary vein isolation (PVI) procedures are reported. Methods and Results— In 65 patients with drug-refractory AF (43 paroxysmal, 22 persistent), complete circumferential PVI was performed using RN in conjunction with different electroanatomic mapping systems. Acute complete PVI using exclusively RN was achieved in 95%. The procedure time was 195±40 minutes. The operator’s x-ray exposure time was reduced by 6±4 minutes (35%) using RN. In 7 of 14 patients with persistent AF, conversion to sinus rhythm was achieved by radiofrequency current ablation. During a median follow-up period of 239 days (range, 184 to 314 days), 47 of 65 patients (73%) remained free of any documented atrial tachyarrhythmia recurrences after a single procedure. The relative proportion of patients remaining free of AF was 76% and 68% for paroxysmal and persistent AF, respectively. Conclusions— PVI using the novel RN system can be performed safely and effectively. One third of the operator’s fluoroscopy exposure time might be saved using RN. However, the questions of whether the overall fluoroscopy exposure is reduced by RN and whether RN improves PVI procedures needs to be assessed during a comparative trial between man and machine. Received August 31, 2008; accepted December 17, 2008. # CLINICAL PERSPECTIVE {#article-title-2}

Cryoballoon Pulmonary Vein Isolation with Real-Time Recordings from the Pulmonary Veins

Introduction: Cryoballoon (CB) ablation represents a novel technology for pulmonary vein isolation (PVI). We investigated feasibility and safety of CB‐PVI, utilizing a novel spiral catheter (SC), thereby obtaining real‐time PV potential registration.