Wilber Su

Best practice guide for cryoballoon ablation in atrial fibrillation: The compilation experience of more than 3000 procedures.

BACKGROUND Since the release of the second-generation cryoballoon (CB2; Arctic Front Advance(TM), Medtronic Inc) and its design modifications with improved cooling characteristics, the technique, dosing, and complication profile is significantly different from that of the first-generation cryoballoon. A comprehensive report of CB2 procedural recommendations has not been reported. OBJECTIVE The purpose of this study was to review the current best practices from a group of experienced centers to create a users consensus guide for CB2 ablation. METHODS/RESULTS High-volume operators with a combined experience of more than 3000 CB2 cases were interviewed, and consensus for technical and procedural best practice was established. CONCLUSION Comprehensive review of the CB2 ablation best practice guide will provide a detailed technique for achieving safer and more effective outcomes for CB2 atrial fibrillation ablation.

2015 ACC/AHA/HRS Advanced Training Statement on Clinical Cardiac Electrophysiology (A Revision of the ACC/AHA 2006 Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion)

Eric S. Williams, MD, MACC, Chair Jonathan L. Halperin, MD, FACC, Co-Chair James A. Arrighi, MD, FACC Eric H. Awtry, MD, FACC Eric R. Bates, MD, FACC John E. Brush, Jr, MD, FACC Salvatore Costa, MD, FACC Lori Daniels, MD, MAS, FACC Akshay Desai, MD, FACC[‡][1] Douglas E. Drachman, MD,

Percutaneous transhepatic approach for cryoballoon pulmonary vein isolation in a patient with persistent atrial fibrillation and interruption of the inferior vena cava

Pulmonary vein isolation (PVI) with Arctic Front cryoballoon has been an effective treatment for paroxysmal atrial fibrillation.1 The recent 2016 European Society of Cardiology guidelines and Heart Rhythm Society Guideline on the management of atrial fibrillation have established PVI as a cornerstone catheter ablation strategy during the primary index ablation for patients with symptomatic and drug-refractory atrial fibrillation.2 Furthermore, these guidelines recognized that cryoballoon catheter ablation can be an effective alternative to the traditional radiofrequency ablation catheters that have been historically used.2 The performance of PVI is typically achieved via the inferior vena cava (IVC) through the access of the femoral veins; however, congenital anomalies or venous occlusion may inhibit the use of this approach. In these rare circumstances, access to the cardiac chambers may be achieved via the superior vena cava or via retrograde aortic approaches. Unfortunately, these approaches are less favorable owing to reduced catheter control, manipulation, and stability.3, 4, 5 The purpose of this case report is to illustrate the safety and efficacy of performing PVI with the Arctic Front cryoballoon catheter via the transhepatic approach among patients with congenital anomalies. Access to the right atrium via the percutaneous transhepatic approach is an alternative method when traditional means are not feasible. The percutaneous transhepatic approach has been shown to be effective, with a complication rate of <5%.6 Although percutaneous transhepatic approach in performing cardiac ablation procedures is traditionally utilized in pediatric cases,6, 7, 8, 9 there is limited data on the transhepatic approach in the adult population.3

Cryoballoon Best Practices II: Practical guide to procedural monitoring and dosing during atrial fibrillation ablation from the perspective of experienced users

Since the evaluation of the cryoballoon in the Sustained Treatment Of Paroxysmal Atrial Fibrillation trial, more than 350,000 patients with atrial fibrillation have been treated. Several studies have reported improved outcomes using the second-generation cryoballoon, and recent publications have evaluated modifications, refinements, and improvements in procedural techniques. Here, peer-reviewed articles published since the first cryoballoon best practices review were summarized against the technical practices of physicians with a high level of experience with the cryoballoon (average ≥6 years of experience in ≥900 cases). This summary includes a comprehensive literature review along with practical usage guidance from physicians using the cryoballoon to facilitate safe, efficient, and effective outcomes for patients with atrial fibrillation.

Utility of intracardiac ultrasound imaging to guide pulmonary vein ablation using laser balloon catheter

FUNDAMENTO: O isolamento das veias pulmonares (IVP) tem sido usado como endpoint para a ablacao da fibrilacao atrial (FA) com cateter balao. OBJETIVO: Determinar a utilidade do ultrassom intracardiaco (USIC) para guiar o IVP, usando cateter balao a laser. METODOS: 59 VP foram ablacionadas em 27 caes. Imagens de Doppler foram usadas para identificar os vazamentos do fluxo sanguineo entre a VP e o balao. Apos cada liberacao de energia, o cateter de mapeamento circular foi reposicionado para verificar se o isolamento tinha sido obtido. A posicao de vazamento foi entao correlacionada com a posicao do gap no estudo patologico. A analise de regressao logistica multivariada foi realizada. RESULTADOS: Cinquenta e nove VP foram submetidas a ablacao. O tempo medio de energia liberada foi de 279±177 seg., o diâmetro medio do balao era de 23±3 mm, e o comprimento medio do balao era 25±4 mm. O isolamento completo foi obtido em 38/59 (64%), e foi significantemente mais comum sem vazamento: [30/38 (79%) versus 8/23 (35%), p<0,001]. Isso foi independente do tempo de aplicacao (302±223 seg. vs. 266±148 sec., p=ns), potencia (3,5 W/cm, 4,5 W/cm, e 5,5 W/cm), diâmetro do balao (24± 3 mm vs. 22± 3 mm, p= ns) e comprimento (27±4 mm vs. 24±4 mm, p=ns). O valor preditivo positivo para previsao de isolamento completo foi de 65% e o valor preditivo negativo foi 83%. CONCLUSAO: Um vazamento identificavel entre a VP e o dispositivo de ablacao por cateter-balao observado no USIC e preditor de menor taxa de isolamento de VP mais baixas. O USIC pode ser util para detectar vazamentos a fim de evitar o uso ineficaz de aplicacao energia durante a ablacao circunferencial da VP. Isto tambem pode ser util quando outras energias sao utilizadas.BACKGROUND Pulmonary vein isolation (PVI) with balloon catheter has been used as the endpoint for AF ablation. OBJECTIVE To determine the usefulness of intracardiac ultrasound (ICUS) to guide PVI using laser balloon catheter. METHODS 59 PVs were ablated in 27 dogs. Doppler imaging was used to identify blood flow leaks between PV and balloon. After each energy delivery, the circular mapping catheter was repositioned to check if isolation had been achieved. The leak position was then correlated with the gap position at the pathological study. Multivariate logistic regression analysis was undertaken. RESULTS 59 PV were ablated. Mean burn time was 279+/-177 sec, mean balloon diameter was 23+/-3 mm, and mean balloon length was 25+/-4 mm. Complete isolation was achieved in 38/59 (64%) cases, and it was significantly more common when there was no leak: [30/38 (79%) versus 8/23 (35%), p<0.001]. This occurred regardless of time of laser application (302+/-223 sec. vs. 266+/-148 sec., p=ns), laser power (3.5 W/cm, 4.5 W/cm, and 5.5 W/cm), balloon diameter (24+/- 3 mm vs. 22+/- 3 mm, p=ns) and length (27+/-4 mm vs. 24+/-4mm, p=ns). The positive predictive value for predicting incomplete isolation was 65% and the negative predictive value was 83%. CONCLUSION An identifiable leak between PV and the LBA device seen at the ICUS is predictive of lower PV isolation rates. ICUS may be useful for leak detection to avoid ineffective energy application during circumferential PV ablation. This could also be helpful when other types of energy are used.

EARLY EXPERIENCE OF TOPERA ROTOR MAPPING FOR THE TREATMENT OF RECURRENT ATRIAL FIBRILLATION FOLLOWING PRIOR PULMONARY VEIN ISOLATION

Introduction: Ablation of persistent and long-standing persistent atrial fibrillation (AF) is challenging. A common approach begins with pulmonary vein isolation (PVI), however when PVI fails the next step is not well defined. Physiologic mapping, such as the Topera system, has been successfully

PROSPECTIVE CRYOBALLOON DOSING STUDY BASED ON TIME-TO-ISOLATION

Background: Cryoballoon ablation is an effective treatment for Paroxysmal Atrial Fibrillation (PAF). Optimal dosing of the second-generation cryoballoon (CB2; Arctic Front AdvanceTM, Medtronic Inc) is still unclear. Time-to-effect (TTE) is the physiologic end-point when acute pulmonary vein signals

Utilidad del ultrasonido intracardíaco en el aislamiento de venas pulmonares usando catéter-balón láser

FUNDAMENTO: O isolamento das veias pulmonares (IVP) tem sido usado como endpoint para a ablacao da fibrilacao atrial (FA) com cateter balao. OBJETIVO: Determinar a utilidade do ultrassom intracardiaco (USIC) para guiar o IVP, usando cateter balao a laser. METODOS: 59 VP foram ablacionadas em 27 caes. Imagens de Doppler foram usadas para identificar os vazamentos do fluxo sanguineo entre a VP e o balao. Apos cada liberacao de energia, o cateter de mapeamento circular foi reposicionado para verificar se o isolamento tinha sido obtido. A posicao de vazamento foi entao correlacionada com a posicao do gap no estudo patologico. A analise de regressao logistica multivariada foi realizada. RESULTADOS: Cinquenta e nove VP foram submetidas a ablacao. O tempo medio de energia liberada foi de 279±177 seg., o diâmetro medio do balao era de 23±3 mm, e o comprimento medio do balao era 25±4 mm. O isolamento completo foi obtido em 38/59 (64%), e foi significantemente mais comum sem vazamento: [30/38 (79%) versus 8/23 (35%), p<0,001]. Isso foi independente do tempo de aplicacao (302±223 seg. vs. 266±148 sec., p=ns), potencia (3,5 W/cm, 4,5 W/cm, e 5,5 W/cm), diâmetro do balao (24± 3 mm vs. 22± 3 mm, p= ns) e comprimento (27±4 mm vs. 24±4 mm, p=ns). O valor preditivo positivo para previsao de isolamento completo foi de 65% e o valor preditivo negativo foi 83%. CONCLUSAO: Um vazamento identificavel entre a VP e o dispositivo de ablacao por cateter-balao observado no USIC e preditor de menor taxa de isolamento de VP mais baixas. O USIC pode ser util para detectar vazamentos a fim de evitar o uso ineficaz de aplicacao energia durante a ablacao circunferencial da VP. Isto tambem pode ser util quando outras energias sao utilizadas.BACKGROUND Pulmonary vein isolation (PVI) with balloon catheter has been used as the endpoint for AF ablation. OBJECTIVE To determine the usefulness of intracardiac ultrasound (ICUS) to guide PVI using laser balloon catheter. METHODS 59 PVs were ablated in 27 dogs. Doppler imaging was used to identify blood flow leaks between PV and balloon. After each energy delivery, the circular mapping catheter was repositioned to check if isolation had been achieved. The leak position was then correlated with the gap position at the pathological study. Multivariate logistic regression analysis was undertaken. RESULTS 59 PV were ablated. Mean burn time was 279+/-177 sec, mean balloon diameter was 23+/-3 mm, and mean balloon length was 25+/-4 mm. Complete isolation was achieved in 38/59 (64%) cases, and it was significantly more common when there was no leak: [30/38 (79%) versus 8/23 (35%), p<0.001]. This occurred regardless of time of laser application (302+/-223 sec. vs. 266+/-148 sec., p=ns), laser power (3.5 W/cm, 4.5 W/cm, and 5.5 W/cm), balloon diameter (24+/- 3 mm vs. 22+/- 3 mm, p=ns) and length (27+/-4 mm vs. 24+/-4mm, p=ns). The positive predictive value for predicting incomplete isolation was 65% and the negative predictive value was 83%. CONCLUSION An identifiable leak between PV and the LBA device seen at the ICUS is predictive of lower PV isolation rates. ICUS may be useful for leak detection to avoid ineffective energy application during circumferential PV ablation. This could also be helpful when other types of energy are used.