A 32-year-old woman with lone paroxysmal atrial fibrillation had two pulmomary vein isolation procedures over 1 year, by means of the circular multipolar duty-cycled radiofrequency PVAC catheter in the first and the Thermocool® SmartTouchTM catheter in the second procedure. Following both procedures, the patient remained highly symptomatic on a weekly to monthly basis and a third procedure was performed by using the second generation of cryoballoon Arctic Front AdvanceTM. Right inferior pulmonary vein was completely reconnected and an extreme hockey stick configuration was necessary in order to achieve complete occlusion and isolation. Thirty months later the patient remains symptom free in the absence of any therapy. Rhythmos 2016;11(4):96-97

Doulamis, Vasilis

Kourgiannidis, George

Stefanadis, Christodoulos

Tsiachris, Dimitris

Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)

96  CASE REPORT  Ablation Techniques in a Patient with a Right Accessory Pulmonary Vein. Is it Always Feasible?  Dimitris Tsiachris, MD1, George Kourgiannidis, MD1,2, Vasilis Doulamis, MD1,2, Christodoulos Stefanadis, MD1  1Athens Heart Center, Athens Medical Center, 2Department of Cardiology, 251 Air Force General Hospital, Athens, Greece * e-mail: dtsiachris@yahoo.com    Abstract  A 32-year-old woman with lone paroxysmal atrial fibrillation had two pulmomary vein isolation procedures over 1 year, by means of the circular multipolar duty-cycled radiofrequency PVAC catheter in the first and the Thermocool® SmartTouchTM catheter in the second procedure. Following both procedures, the patient remained highly symptomatic on a weekly to monthly basis and a third procedure was performed by using the second generation of cryoballoon Arctic Front AdvanceTM. Right inferior pulmonary vein was completely reconnected and an extreme hockey stick configuration was necessary in order to achieve complete occlusion and isolation. Thirty months later the patient remains symptom free in the absence of any therapy. Rhythmos 2016;11(4):96-97.   Key words: cryoablation; pulmonary vein isolation  Abbreviations: AF = atrial fibrillation; PV = pulmonary vein   Short title: Is pulmonary vein isolation always feasible?  Sources of financial support: None declared  Manuscript submitted may 15, 2016; revised manuscript submitted July 26, 2016; Accepted August 12, 2016  INTRODUCTION  Ablation techniques for atrial fibrillation (AF) are plagued by frequent early and late recurrences, reported to occur in around 30-50% of patients, requiring repeat ablation, which is subsequently associated with better long-term freedom from recurrent AF.1 The main reason for AF recurrences after an initial procedure is mostly related to reconnections at some segments of the perimeter of pulmonary veins (PV), rather than extrapulmonary sources.1 Pulmonary vein anatomy may also explain the variable outcome to electrical isolation in patients with paroxysmal AF, since 4 discrete PVs are present in the minority of patients with paroxysmal AF undergoing PV isolation.2 We present a case of a successful third attempt of PV isolation in a patient with a right accessory PV by means of cryoablation.    CASE REPORT A 32-year-old woman with lone paroxysmal AF had 2 PV isolation procedures over 1 year. The circular multipolar duty-cycled radiofrequency PVAC catheter (Ablation Frontiers, Medtronic) was used in the first procedure both as a diagnostic catheter for PV potentials as well as an ablation catheter, indicating complete PV isolation. Following the intervention, she experienced recurrence of palpitations within a few days, clearly documented as paroxysms of AF despite antiarrhythmic therapy. She was offered a second ablation 6 months later, as she continued to be highly symptomatic on a weekly basis. Thermocool® SmartTouchTM (Biosense Webster©) with continuous assessment of catheter–tissue contact and three dimensional electroanatomic mapping system Carto 3® was used in the second procedure. A circumferential mapping catheter (LassoTM; BiosenseWebster©) confirmed full PV disconnection and both entrance and exit block at the end of the procedure. Following the second procedure, the patient remained highly symptomatic on a weekly to monthly basis and a third procedure seemed inevitable. Preprocedural imaging of the left atrium and PVs by magnetic resonance imaging exhibited a right middle PV and a perpendicular outlet of a right lower PV (Fig. 1). Despite the challenging PV anatomy, the second generation of cryoballoon, Arctic Front AdvanceTM, was selected for the third procedure. A 15 French deflectable sheath (FlexCath® Medtronic©) was introduced into the left atrium after a single transseptal puncture. The circular Achieve® Catheter (Medtronic©) was used to assess electrical activity within each PV.  It was confirmed that the left inferior, right superior and right middle PVs remained isolated. Minor electrical activity was present within the left superior PV while the right inferior PV was completely reconnected. Then, a 28-mm Arctic Front AdvanceTM balloon was inflated and advanced to the ostium of left superior PV and an application of 180 seconds was delivered since isolation was evident after only 25 seconds of ablation. Occlusion of the right inferior PV could not be achieved with a direct approach, the pull-down technique or the big loop technique as presented by Chun et al.3 Finally, the Achieve® Catheter was placed deep in the right inferior PV. The sheath was then advanced with maximal bent to roof of the left atrium, allowing the balloon to be pushed into the inferior part of the PV ostium, which resulted in an extreme hockey stick configuration and complete PV occlusion (Fig. 2). A 240-sec application was delivered with continuous monitoring of the right phrenic nerve performed by high-output pacing through a hexapolar catheter in the superior vena cava. Administration of 97  adenosine did not reveal any left atrial–PV conduction in any vein. The patient was symptom free immediately after the third procedure and antiarrhythmic therapy was discontinued 3 months during the blanking period. Thirty months later she remains free of symptoms in the absence of any therapy.  DISCUSSION  Pulmonary vein isolation with use of radiofrequency ablation is the most common ablation technique for paroxysmal and/or persistent AF. Using cryothermic ablation via a cryoballoon is an alternative rapidly growing technique and the second generation cryoballoon is considered to deliver more effective lesions.4 These approaches, however, are limited by fixed balloon sizes which do not sufficiently account for the variable PV anatomy. We assume that the accessory right PV rather than the minor electrical activity in the left superior PV was the main cause of arrhythmogenicity and AF recurrences in our case. This challenging anatomy did not allow long-term PV isolation despite the use of the novel contact force irrigated catheter in the second procedure.  The key message of the present case report is to indicate the role of preprocedural imaging and present specific techniques that may be used in order to occlude any vein in cryoablation procedures. Preprocedural imaging of the left atrium and PVs (e.g. by computed tomography, magnetic resonance imaging, rotational angiography) reveals the individual cardiac anatomy and facilitates catheter ablation, especially after a failed procedure. Finally, the extreme hockey-stick transformation with the support of left atrium roof is recommended in inferior PVs with a perpendicular outlet.    REFERENCES  1. Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: Recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Heart Rhythm 2012;9:632-696. 2. McLellan AJ, Ling LH, Ruggiero D, et al. Pulmonary vein isolation: the impact of pulmonary venous anatomy on long-term outcome of catheter ablation for paroxysmal atrial fibrillation. Heart Rhythm 2014;11:549-556. 3. Chun KR, Schmidt B, Metzner A, et al. The 'single big cryoballoon' technique for acute pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a prospective observational single centre study. Eur Heart J 2009;30:699-709.  4. Manolis AS, Avramidis D, Papadimitriou P, Poulidakis E, Tzagarakis J, Kappos K. CryoAblation of Atrial Fibrillation: New Technique/ New expectations. Hosp Chronicles 2014;9:208-209.     Figure 1. Preprocedural imaging of the left atrium and pulmonary veins by magnetic resonance imaging exhibited a right middle pulmonary vein and a perpendicular outlet of a right lower pulmonary vein.     Figure 2. The sheath is advanced with maximal bend to roof of the left atrium, allowing the balloon to be pushed into the inferior part of the pulmonary vein ostium resulting in an extreme hockey stick configuration and complete occlusion (right panel) while the Achieve® Catheter is moved towards the ostium of the right inferior pulmonary vein (left panel).    

Ablation Techniques in a Patient with a Right Accessory Pulmonary Vein. Is it Always Feasible?

A 32-year-old woman with lone paroxysmal atrial fibrillation had two pulmomary vein isolation procedures over 1 year, by means of the circular multipolar duty-cycled radiofrequency PVAC in the first and the Thermocool® SmartTouchTM catheter in the second procedure. Following both procedures, the patient remained highly symptomatic on a weekly to monthly basis and a third procedure by using the second generation of cryoballoon Arctic Front AdvanceTM. Right inferior pulmonary vein was completely reconnected and an extreme hockey stick configuration was necessary in order to achieve complete occlusion and isolation. Thirty months later the patient remains symptom free in the absence of any therapy

Hospital Chronicles (E-Journal)

Ablation Techniques in a Patient With  a Right Accessory Pulmonary Vein.  Is it Always Feasible?*Dimitris Tsiachris, MD,1 George Kourgiannidis, MD,1,2  Vasilis Doulamis, MD,1,2 Christodoulos Stefanadis, MD1A b s t r A c tA 32-year-old woman with lone paroxysmal atrial fibrillation had two pulmomary vein isolation procedures over 1 year, by means of the circular multipolar duty-cycled radi-ofrequency PVAC in the first and the Thermocool® SmartTouchTM catheter in the sec-ond procedure. Following both procedures, the patient remained highly symptomatic on a weekly to monthly basis and a third procedure by using the second generation of cryoballoon Arctic Front AdvanceTM was performed. Right inferior pulmonary vein was completely reconnected and an extreme hockey stick configuration was necessary in order to achieve complete occlusion and isolation. Thirty months later the patient remains symptom free in the absence of any therapy.I n t r o d u c t I o nAblation techniques for atrial fibrillation (AF) are plagued by frequent early and late recurrences, reported to occur in around 30-50% of patients, requiring reabla-tion, which is subsequently associated with better long-term freedom from recurrent AF.1 The main reason for AF recurrences after an initial procedure is mostly related to reconnections at some segments of the perimeter of pulmonary veins (PV), rather than extrapulmonary sources.1 PV anatomy may also explain the variable outcome to electrical isolation in patients with paroxysmal AF, since 4 discrete PVs are present in the minority of patients with paroxysmal AF undergoing PV isolation.2 We present a case of a successful third attempt of PV isolation in a patient with a right accessory PV by means of cryoablation.c A s e  r e p o r tA 32-year-old woman with lone paroxysmal AF had 2 PV isolation procedures over 1 year. The circular multipolar duty-cycled radiofrequency PVAC (Ablation Frontiers, Medtronic), was used in the first procedure both as a diagnostic catheter for PV po-cAse reportAthens Heart Center, Athens Medical Center, Athens, Greece Department of Cardiology,  251 Air Force General Hospital, Athens, GreeceHOSPITAL CHRONICLES 2016, 11(4): 221–223Correspondence to:Dimitris Tsiachris, MD,  5-7 Distomou street,  Maroussi 151 25, Greece;  Tel.: +30-6944849926;  fax: +30-2106862594;  e-mail: dtsiachris@yahoo.comKey words: cryoablation; pulmonary vein isolationAbbreviAtions:AF: atrial fibrillationPV: pulmonary veinSources of financial support: None declared * Reproduced with permission from: Rhythmos 2016;11(4):96-97.222HOSPITAL CHRONICLES 11(4), 2016tentials as well as an ablation catheter, indicating complete PV isolation. Following the intervention she experienced recur-rence of palpitations within a few days, clearly documented as paroxysms of AF despite antiarrhythmic therapy. She was offered a second ablation 6 months later, as she continued to be highly symptomatic on a weekly basis. Thermocool® Smart-TouchTM (Biosense Webster©) with continuous assessment of catheter–tissue contact and three dimensional electroanatomic mapping system Carto 3® was used in the second procedure. A circumferential mapping catheter (LassoTM; BiosenseWeb-ster©) confirmed full PV disconnection and both entrance and exit block. Following the second procedure, the patient remained highly symptomatic on a weekly to monthly basis and a third procedure seemed inevitable.Preprocedural imaging of the left atrium and PVs by mag-netic resonance imaging exhibited a right middle PV and a perpendicular outlet of a right lower PV (Figure 1). Despite the challenging PV anatomy, the second generation of cryoballoon, Arctic Front AdvanceTM was selected for the third procedure. A 15 French deflectable sheath (FlexCath® Medtronic©) was introduced into the left atrium after a single transseptal punc-ture. The circular Achieve® Catheter (Medtronic©) was used to assess electrical activity within each PV.Left inferior, right superior and right middle PVs were isolated. Minor electrical activity was present within the left superior PV while right inferior PV was completely recon-nected. Then, a 28-mm Arctic Front AdvanceTM balloon was inflated and advanced to the ostium of left superior PV and an application of 180 seconds was delivered since isolation was evident after only 25 seconds of ablation. Occlusion of the right inferior PV could not be achieved with a direct approach, the pull down technique or the big loop technique as presented by Chun et al.3 Finally, the Achieve® Catheter was placed deep in the right inferior PV. The sheath was then advanced with maximal bend to roof of the left atrium, allowing the balloon to be pushed into the inferior part of the PV ostium, which resulted in an extreme hockey stick configuration and complete PV occlusion (Figure 2). A 240 sec application was delivered FIgure 1. Preprocedural imaging of the left atrium and pulmo-nary veins by magnetic resonance imaging exhibited a right mid-dle pulmonary vein and a perpendicular outlet of a right lower pulmonary vein. FIgure 2. The sheath is advanced with maximal bend to roof of the left atrium, allowing the balloon to be pushed into the in-ferior part of the pulmonary vein ostium resulting in an extreme hockey stick configuration and complete occlusion (A panel) while the Achieve® Catheter is moved towards the ostium of the right inferior pulmonary vein (B panel).ΑbIS PuLMONARy VEIN ISOLATION ALWAyS FEASIBLE?223with continuous monitoring of the right phrenic nerve per-formed by high-output pacing through a hexapolar catheter in the superior vena cava. Administration of adenosine did not reveal any left atrial–PV conduction in any vein. The patient was symptom free immediately after the third procedure and antiarrhythmic therapy was discontinued 3 months during the blanking period. Thirty months later she remains symptom free in the absence of any therapy.d I s c u s s I o nPulmonary vein isolation with use of radiofrequency abla-tion is the most common ablation technique for paroxysmal and/or persistent AF. using cryothermic ablation via a cry-oballoon is an alternative rapidly growing technique and the second generation cryoballoon is considered to deliver more effective lesions.4 These approaches, however, are limited by fixed balloon sizes which do not sufficiently account for the variable PV anatomy. We assume that the accessory right PV rather than the minor electrical activity in the left superior PV was the main cause of arrhythmogenicity and AF recurrences in our case. This challenging anatomy did not allow long-term PV isolation despite the use of the novel contact force irrigated catheter in the second procedure. The key messages of the present case report is to indi-cate the role of preprocedural imaging and present specific techniques that may be used in order to occlude any vein in cryoablation procedures. Preprocedural imaging of the left atrium and PVs [e.g. by computed tomography, magnetic reso-nance imaging, rotational angiography] reveales the individual cardiac anatomy and facilitates catheter ablation, especially after a failed procedure. Finally, the extreme hockey-stick transformation with the support of left atrium roof is recom-mended in inferior PVs with a perpendicular outlet.A c K n o w l e d g e m e n t sNothing to declare.r e F e r e n c e s1. Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: Recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Heart Rhythm 2012; 9:632-696.2. McLellan AJ, Ling LH, Ruggiero D, et al. Pulmonary vein iso-lation: the impact of pulmonary venous anatomy on long-term outcome of catheter ablation for paroxysmal atrial fibrillation. Heart Rhythm 2014; 11:549-556.3. Chun KR, Schmidt B, Metzner A, et al. The ‘single big cryobal-loon’ technique for acute pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a prospective observational single centre study. Eur Heart J 2009; 30:699-7094. Manolis AS, Avramidis D, Papadimitriou P, Poulidakis E, Tzagarakis J, Kappos K. CryoAblation of Atrial Fibrillation: New Technique/New expectations. Hospital Chronicles 2014; 9:208-209.

http://www.rhythmos.gr/index.php/Rhythmos/article/download/234/188

Ablation Techniques in a Patient with a Right Accessory Pulmonary Vein. Is it Always Feasible?

Abstract

Similar works

Full text

Available Versions

Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)

Hospital Chronicles (E-Journal)