Case report: Managing profound circulatory collapse post-atrial fibrillation ablation: a methodical approach

BACKGROUND: Circulatory collapse during/post-pulmonary vein (PV) isolation by cryo-balloon ablation is a Cardiology emergency that has multiple potential causes and requires a methodical investigative approach. Some of the complications that can arise include cardiac tamponade, bleeding/vascular injury, anaphylaxis, Addisonian crisis, acute pulmonary embolism, acute PV stenosis, oesophageal injury, and vagal reaction. CASE SUMMARY: Here, we present a case of a 76-year-old lady who developed profound circulatory collapse during an elective pulmonary vein isolation by cryo-balloon ablation for symptomatic paroxysmal atrial fibrillation (AF). Cardiac tamponade, bleeding/vascular injury, and other less common causes were excluded. She only responded transiently to fluid resuscitation and developed intermittent bradyarrhythmias and hypotension which responded to isoprenaline. She was discharged home at Day 3 post-AF ablation after remaining well and continued to do so at follow-up. DISCUSSION: Circulatory collapse during/post-PV cryo-balloon ablation is a Cardiology emergency that has multiple potential causes. The ganglionate plexi form part of the cardiac intrinsic autonomic nervous system (ANS) and are located close to the left atrial–PV junctions. The presence of vagal response has been observed to be a marker of ANS modulation although its significance on the long-term outcome post-ablation has yet to be elucidated. The true cause of our patient’s profound circulatory collapse is uncertain but a vital learning point in this case is the systematic exclusion of common and potentially life-threatening complications following AF ablation. A persistent vagal reaction secondary to PV cryo-balloon ablation can usually be managed with supportive medical therapy as demonstrated in our case

Atrial fibrillation cryoablation is an effective day case treatment: the UK PolarX vs. Arctic Front Advance experience

\ua9 The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. AIMS: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF). There are limited data on the PolarX Cryoballoon. The study aimed to establish the safety, efficacy, and feasibility of same day discharge for Cryoballoon PVI. METHODS AND RESULTS: Multi-centre study across 12 centres. Procedural metrics, safety profile, and procedural efficacy of the PolarX Cryoballoon with the Arctic Front Advance (AFA) Cryoballoon were compared in a cohort large enough to provide definitive comparative data. A total of 1688 patients underwent PVI with cryoablation (50% PolarX and 50% AFA). Successful PVI was achieved with 1677 (99.3%) patients with 97.2% (n = 1641) performed as day case procedures with a complication rate of <1%. Safety, procedural metrics, and efficacy of the PolarX Cryoballoon were comparable with the AFA cohort. The PolarX Cryoballoon demonstrated a nadir temperature of -54.6 \ub1 7.6\ub0C, temperature at 30 s of -38.6 \ub1 7.2\ub0C, time to -40\ub0C of 34.1 \ub1 13.7 s, and time to isolation of 49.8 \ub1 33.2 s. Independent predictors for achieving PVI included time to reach -40\ub0C [odds ratio (OR) 1.34; P < 0.001] and nadir temperature (OR 1.24; P < 0.001) with an optimal cut-off of ≤34 s [area under the curve (AUC) 0.73; P < 0.001] and nadir temperature of ≤-54.0\ub0C (AUC 0.71; P < 0.001), respectively. CONCLUSIONS: This large-scale UK multi-centre study has shown that Cryoballoon PVI is a safe, effective day case procedure. PVI using the PolarX Cryoballoon was similarly safe and effective as the AFA Cryoballoon. The cryoablation metrics achieved with the PolarX Cryoballoon were different to that reported with the AFA Cryoballoon. Modified cryoablation targets are required when utilizing the PolarX Cryoballoon

Atrial fibrillation cryoablation is an effective day case treatment: the UK PolarX vs. Arctic Front Advance experience.

AIMS: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF). There are limited data on the PolarX Cryoballoon. The study aimed to establish the safety, efficacy, and feasibility of same day discharge for Cryoballoon PVI. METHODS AND RESULTS: Multi-centre study across 12 centres. Procedural metrics, safety profile, and procedural efficacy of the PolarX Cryoballoon with the Arctic Front Advance (AFA) Cryoballoon were compared in a cohort large enough to provide definitive comparative data. A total of 1688 patients underwent PVI with cryoablation (50% PolarX and 50% AFA). Successful PVI was achieved with 1677 (99.3%) patients with 97.2% (n = 1641) performed as day case procedures with a complication rate of <1%. Safety, procedural metrics, and efficacy of the PolarX Cryoballoon were comparable with the AFA cohort. The PolarX Cryoballoon demonstrated a nadir temperature of -54.6 ± 7.6°C, temperature at 30 s of -38.6 ± 7.2°C, time to -40°C of 34.1 ± 13.7 s, and time to isolation of 49.8 ± 33.2 s. Independent predictors for achieving PVI included time to reach -40°C [odds ratio (OR) 1.34; P < 0.001] and nadir temperature (OR 1.24; P < 0.001) with an optimal cut-off of ≤34 s [area under the curve (AUC) 0.73; P < 0.001] and nadir temperature of ≤-54.0°C (AUC 0.71; P < 0.001), respectively. CONCLUSIONS: This large-scale UK multi-centre study has shown that Cryoballoon PVI is a safe, effective day case procedure. PVI using the PolarX Cryoballoon was similarly safe and effective as the AFA Cryoballoon. The cryoablation metrics achieved with the PolarX Cryoballoon were different to that reported with the AFA Cryoballoon. Modified cryoablation targets are required when utilizing the PolarX Cryoballoon

withdrawn 2017 hrs ehra ecas aphrs solaece expert consensus statement on catheter and surgical ablation of atrial fibrillation

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Relevance of electrical connectivity between the coronary sinus and the left atrial appendage for the intentional electrical isolation of the left atrial appendage in treating persistent atrial fibrillation: insights from the LEIO-AF study

Catheter ablation is an accepted therapeutic option for paroxysmal atrial fibrillation (AF), but its role is less certain in patients with persistent AF.1 The difference in response to pulmonary vein (PV) isolation (PVI) between paroxysmal and persistent forms of AF may arise because of triggers from non-PV sites or alterations in atrial substrate favoring maintenance of AF that are unaffected by PVI alone.2 In support of this statement, adjunctive ablation of certain sites (including the superior vena cava, ligament of Marshall [LOM], crista terminalis, coronary sinus [CS], posterior wall of the left atrium [LA], and left atrial appendage [LAA]) as well as more widespread ablation aimed at modifying substrate has been shown to improve the success of catheter ablation of persistent AF. In the case of the LAA, the BELIEF study (Effect of Empirical Left Atrial Appendage Isolation on Long-term Procedure Outcome in Patients With Persistent or Long-standing Persistent Atrial Fibrillation Undergoing Catheter Ablation)3 recently showed that in patients with long-standing persistent AF, empirical electrical isolation of the LAA together with extensive atrial ablation markedly improved freedom from AF at 1 year compared to an extensive atrial ablation strategy alone. However, electrical isolation of the LAA can be challenging and is sometimes impossible to achieve. This may be partly because the electrical connections of the LAA are not completely understood. Here we report 2 patients showing that the CS can be an important electrical conduit to the LAA

Evaluation of a novel high-resolution mapping system for catheter ablation of ventricular arrhythmias.

BACKGROUND: The mapping of ventricular arrhythmias in humans using a minibasket 64-electrode catheter paired with a novel automatic mapping system (Rhythmia) has not been evaluated. OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of mapping ventricular arrhythmias and clinical outcomes after ablation using this system. METHODS: Electroanatomic maps for ventricular arrhythmias were obtained during 20 consecutive procedures in 19 patients (12 with ventricular tachycardia [VT] and 2 with ventricular ectopy [VE]). High-density maps were acquired using automatic beat acceptance and automatic system annotation of electrograms. RESULTS: Forty-seven electroanatomic maps (including 3 right ventricular and 9 epicardial maps) were obtained. Left ventricular endocardial mapping by transseptal (n = 13) and/or transaortic (n = 11) access was safe with no complications related to the minibasket catheter. VT substrate maps (n = 14; median 10,184 points) consistently demonstrated late potentials with high resolution. VT activation maps (n = 25; median 6401 points) obtained by automatic annotation included 7 complete maps (covering ≥90% of the tachycardia cycle length) in 5 patients in whom the entire VT circuit was accurately visualized. VE timing maps (n = 8) successfully localized the origin of VEs in all, with all accepted beats consistent with clinical VEs. Over a median follow-up of 10 months, no arrhythmia recurrence was noted in 75% after VT ablation and 86% after VE ablation. CONCLUSION: In this first human experience for ventricular arrhythmias using this system, ultra-high-density maps were created rapidly and safely, with a reliable automatic annotation of VT and consistent recording of abnormal electrograms. Medium-term outcomes after ablation were encouraging. Further larger studies are needed to validate these findings

Utility of a novel rapid high-resolution mapping system in the catheter ablation of arrhythmias: an initial human experience of mapping the atria and the left ventricle.

OBJECTIVES: This study sought to assess the clinical efficacy, safety, and clinical utility of a novel electroanatomical mapping system. BACKGROUND: A new mapping system capable of rapidly acquiring detailed maps based on automatic annotation of thousands of points was recently released for clinical use. This is the first description of its utility in humans. METHODS: The first consecutive 20 cases (7 atrial tachycardia, 8 atrial fibrillation, 3 ventricular tachycardia, and 2 ventricular ectopic beat ablations) were analyzed. The system uses a bidirectional deflectable basket catheter with 64 closely spaced mini-electrodes. It automatically accepts and annotates electrograms when a number of predefined criteria are met. RESULTS: Thirty right atrial maps were acquired in 11 (4 to 15) min, consisting of 7,220 (3,467 to 10,947) points, 22 left atrial maps in 11 (6 to 19) min, consisting of 7,818 (4,379 to 12,262) points and 10 left ventricular maps in 37 (14 to 43) min, consisting of 8,709 (2,605 to 15,514) points. The mini-basket catheter could reach all areas of interest without deflectable sheaths. No embolic events, bleeding complications, or endocardial structure damage were observed. Correction of the automatic annotation was performed in 0.02% of points in 4 of 62 maps. The system revealed re-entry circuits of atrial tachyarrhythmias, identified gaps on linear lesions, and identified and correctly annotated the clinical ventricular ectopic beats and channels of slow conduction within ventricular scar. CONCLUSIONS: The novel automatic mapping system was rapid, safe, and efficacious in mapping a variety of cardiac arrhythmias in humans. Further clinical research is needed to optimize its use in the ablation of complex arrhythmias

Impact of a high-density grid catheter on long-term outcomes for structural heart disease ventricular tachycardia ablation

Background: Substrate mapping has highlighted the importance of targeting diastolic conduction channels and late potentials during ventricular tachycardia (VT) ablation. State-of-the-art multipolar mapping catheters have enhanced mapping capabilities. The purpose of this study was to investigate whether long-term outcomes were improved with the use of a HD Grid mapping catheter combining complementary mapping strategies in patients with structural heart disease VT. Methods: Consecutive patients underwent VT ablation assigned to either HD Grid, Pentaray, Duodeca, or point-by-point (PbyP) RF mapping catheters. Clinical endpoints included recurrent anti-tachycardia pacing (ATP), appropriate shock, asymptomatic non-sustained VT, or all-cause death. Results: Seventy-three procedures were performed (33 HD Grid, 22 Pentaray, 12 Duodeca, and 6 PbyP) with no significant difference in baseline characteristics. Substrate mapping was performed in 97% of cases. Activation maps were generated in 82% of HD Grid cases (Pentaray 64%; Duodeca 92%; PbyP 33% (p = 0.025)) with similar trends in entrainment and pace mapping. Elimination of all VTs occurred in 79% of HD Grid cases (Pentaray 55%; Duodeca 83%; PbyP 33% (p = 0.04)). With a mean follow-up of 372 ± 234 days, freedom from recurrent ATP and shock was 97% and 100% respectively in the HD Grid group (Pentaray 64%, 82%; Duodeca 58%, 83%; PbyP 33%, 33% (log rank p = 0.0042, p = 0.0002)). Conclusions: This study highlights a step-wise improvement in survival free from ICD therapies as the density of mapping capability increases. By using a high-density mapping catheter and combining complementary mapping strategies in a strict procedural workflow, long-term clinical outcomes are improved