Balloon catheter ablation to treat paroxysmal atrial fibrillation: What is the level of pulmonary venous isolation?

doi:10.1016/j.hrthm.2007.11.006

Heart Rhythm

Volume 5, Issue 3, March 2008, Pages 353-360

https://doi.org/10.1016/j.hrthm.2007.11.006 Get rights and content

Background

Unlike the initial balloon ablation catheters that were designed to deliver ablation lesions within the pulmonary veins (PVs), the current balloon prototypes are fashioned to deliver lesions at the PV ostia.

Objective

Using electroanatomical mapping, this study evaluates the actual location of ablation lesions generated by cryo-based, laser-based, or ultrasound-based balloon catheters.

Methods

In a total of 14 patients with paroxysmal atrial fibrillation, PV isolation was performed using either a cryoballoon catheter (8 patients), laser catheter (4 patients) or ultrasound balloon catheter (2 patients). Patients underwent preprocedural computed tomographic/magnetic resonance imaging. An intracardiac ultrasound catheter was used to aid in positioning the balloon catheter at the PV ostium/antrum. In all patients, sinus rhythm bipolar voltage amplitude maps (using either CARTO with computed tomographic/magnetic resonance image integration or NavX mapping) were generated at baseline and after electrical PV isolation as confirmed by use of a circular mapping catheter.

Results

Electrical isolation was achieved in 100% of the PVs. Electroanatomical mapping revealed that after ablation with any of the 3 balloon catheters, the extent of isolation included the tubular portions of each PV to the level of the PV ostia. However, the PV antral portions were left largely unablated with all 3 balloon technologies.

Conclusion

Using the current generation of balloon ablation catheters, electrical isolation occurs at the level of the PV ostia, but the antral regions are largely unablated.

Introduction

Electrical pulmonary venous (PV) disconnection is an effective means to treat patients with paroxysmal atrial fibrillation (AF).1, 2, 3, 4, 5, 6, 7, 8 Because of the technical difficulties associated with point-to-point ablation using a standard spot ablation catheter with the left atrium (LA), there has been a significant effort in developing alternative ablation catheter designs to quickly and easily isolate PVs. The first such device tested clinically was an ultrasound balloon ablation catheter that delivered energy in a radial fashion at the level of the diameter of the balloon, hence necessitating that the balloon catheter be placed within the PV when delivering energy.⁹ This balloon design was suboptimal because the level of electrical isolation typically excluded the proximal portions of the vein, so PV triggers of AF located at this region would not be included in the ablation lesion.¹⁰ Also, from a safety perspective, the intravenous location of the energy delivery resulted in PV stenosis.

Since this first-generation device, balloon ablation catheters have evolved considerably.¹¹ There are now 3 major balloon-based ablation devices at various stages of clinical evaluation: (1) cryoballoon ablation, (2) endoscopic laser ablation, and (3) high-intensity focused ultrasound (HIFU). Each of these has been fashioned to be placed at the PV ostia so as to theoretically isolate the veins outside their tubular portion. In this study, detailed electroanatomical mapping (EAM) was performed after balloon ablation using each of these 3 ablation strategies in patients with paroxysmal AF to assess the true anatomical location of electrical PV isolation.

Section snippets

Methods

All procedures were performed after written informed consent according to institutional guidelines at the Massachusetts General Hospital and Homolka Hospital. In a total of 50 patients with paroxysmal AF in whom at least 1 membrane-active antiarrhythmic drug had failed, we performed catheter ablation using either a cryoablation, laser, or HIFU balloon ablation catheter. The cohort of patients discussed in this report represents the 14 patients within this group who underwent detailed LA-PV EAM

Results

Of the 50 patients who underwent balloon catheter ablation, preablation and postablation EAM was performed on 8, 4, and 2 patients with the cryoablation, laser, and HIFU balloon catheters, respectively. The average LA size was 43.6 ± 3.9 mm for the complete patient cohort and 41.5, 46.8, and 45.5 mm for the patients treated with the cryoballoon, laser balloon, and HIFU balloon catheters, respectively. The majority of the patient cohort (9 of 14, 64%) had 4 relatively distinct PVs: 4 and 2

Discussion

The key findings of this study are: (1) the 3 balloon ablation catheter designs are all capable of electrically isolating the PVs outside the tubular portions of the PVs at the level of the PV ostia, and (2) the PV antra are left largely unaffected by this ablation stratagem.

The importance of PV isolation during catheters ablation of paroxysmal AF has been established as a result of several key clinical observations.1, 2, 3, 4, 5, 6, 7, 8 First was the initial description that the PVs harbor

Conclusion

When treating patients with paroxysmal atrial fibrillation, balloon ablation catheters are able to isolate the PVs outside the level of the tubular vein. However, the current generation of balloon ablation catheters leaves the veins’ proximal antral regions unablated.

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Cited by (118)

Pulmonary Vein Isolation With and Without Posterior Wall Isolation in Paroxysmal Atrial Fibrillation: IMPPROVE-PAF Trial
2023, JACC: Clinical Electrophysiology
Prior studies have demonstrated clinical benefits associated with cryoballoon pulmonary vein isolation (PVI) and concomitant posterior wall isolation (PWI) in patients with persistent atrial fibrillation (AF). However, the role for this approach in patients with paroxysmal atrial fibrillation (PAF) remains unclear.
This study investigated the acute and long-term outcomes of PVI vs PVI+PWI using cryoballoon in patients with symptomatic PAF.
This retrospective study (NCT05296824) examined the outcomes of cryoballoon PVI (n = 1,342) vs cryoballoon PVI+PWI (n = 442) in patients with symptomatic PAF during long-term follow-up. Using the nearest-neighbor method, a 1:1 matched sample of patients receiving PVI alone and PVI+PWI was created.
The matched cohort consisted of 320 patients (PVI: n = 160; PVI+PWI: n = 160). PVI+PWI was associated with longer cryoablation (23 ± 10 minutes vs 42 ± 11 minutes; P < 0.001) and procedure times (103 ± 24 minutes vs 127 ± 14 minutes; P < 0.001). In 39 (24.4%) of 160 patients, adjunct radiofrequency ablation was required for PVI+PWI. Adverse event rates were similar (PVI 3.8% vs PVI+PWI 1.9%; P = 0.31). Though there were no differences at 12 months, freedom from all atrial arrhythmias (67.5% vs 45.0%; P < 0.001) and AF (75.6% vs 55.0%; P < 0.001) were significantly greater with PVI+PWI vs PVI alone at 39 ± 9 months of follow-up. PVI+PWI was also associated with reduced long-term need for cardioversion (16.9% vs 27.5%; P = 0.02) and repeat catheter ablation (11.9% vs 26.3%; P = 0.001), and emerged as the only significant predictor of freedom from recurrent AF (HR: 2.79; 95% CI: 1.64-4.74; P < 0.001).
Compared with cryoballoon PVI, cryoballoon PVI+PWI appears to be associated with greater freedom from recurrent atrial arrhythmias and AF in patients with PAF during long-term follow-up >3 years.
Thermal ablation induced by low-intensity ultrasound for pulmonary vein isolation
2022, Applied Acoustics
Atrial fibrillation (AF) is currently the most common arrhythmia disease in clinic and its incidence increases with the age, which seriously endangers peoples health. Percutaneous catheter ablation is an important treatment strategy for AF, and pulmonary vein (PV) isolation has been widely accepted as the key approach of AF ablation since AFs are regarded the most important trigger of AF. The ablation scheme based on low-intensity ultrasound has the advantages of low biotoxicity and minimal invasion, while its applicability and parameter settings are still not well known. In this paper, we proposed a finite element model that could be used to simulate the ablation application of ultrasound intervention device for the purpose of PV isolation. The acoustic pressure and temperature fields generated during the process of low-intensity ultrasound pulmonary vein ablation were simulated based on linear acoustic wave equation and Pennes biological heat transfer equation, and then the corresponding thermal damage was quantitatively analyzed by taking into account of the equivalent heat dose equation. The results showed that the incident acoustic energy was mainly concentrated in the blood vessels of PV, and the temperature rise was mainly constrained in the inner part of the vessel walls, which suggested that high temperature rise could be realized nearby the central region of the low-intensity ultrasound transducer to achieve significant thermal damage in the inner part of the vessel walls. Moreover, the current study also discussed the impacts of different parameters on the ultrasound ablation effect, which would provide theoretical support and guidance for the optimization of ultrasound ablation strategy in clinics.
Segmental nonocclusive cryoballoon ablation of pulmonary veins and extrapulmonary vein structures: Best practices III
2021, Heart Rhythm
Although cryoballoon ablation of atrial fibrillation (AF) traditionally has been guided by pulmonary vein (PV) occlusion, there is evidence and growing interest in performing segmental, nonocclusive cryoballoon ablation to target not only large/common PVs but extra-PV structures such as the left atrial (LA) roof and posterior wall in conjunction with PV isolation. A number of studies have demonstrated improved clinical efficacy associated with nonocclusive cryoballoon ablation of the LA roof and posterior wall in addition to PV isolation, particularly in patients with persistent AF. Not only can the cryoballoon be used for targeting extra-PV structures through segmental, nonocclusive ablation, but the large size and durability of cryolesions coupled with the enhanced stability afforded through cryoadhesion render the cryoballoon an effective tool for such an approach. This article reviews the rationale and practical approach to segmental, nonocclusive cryoballoon ablation of large/common PV antra and the LA roof and posterior wall.
Wide-area antral pulmonary vein and posterior wall isolation by way of segmental nonocclusive applications using a novel radiofrequency ablation balloon
2021, HeartRhythm Case Reports
Does pulsed field ablation regress over time? A quantitative temporal analysis of pulmonary vein isolation
2021, Heart Rhythm
The tissue specificity of pulsed field ablation (PFA) makes it an attractive energy source for pulmonary vein (PV) isolation (PVI). However, beyond each PFA lesion’s zone of irreversible electroporation and cell death, there may be a surrounding zone of reversible electroporation and cell injury that could potentially normalize with time.
The purpose of this study was to assess whether the level of electrical PVI that is observed acutely after PFA regresses over time.
In a clinical trial, patients with paroxysmal atrial fibrillation underwent PVI using a biphasic PFA waveform delivered through a dedicated, variably deployable multielectrode basket/flower catheter. Detailed voltage maps were created using a multispline diagnostic catheter immediately after PFA and again ∼3 months later in a prospective, protocol-specified reassessment procedure. We analyzed 20 patients who underwent PFA with durable PVI and available maps from both time points. To compare the ablated zones, the left- and right-sided PV antral isolation areas and nonablated posterior wall area were quantified and the distances between left and right PV low-voltage edges were measured.
A comparison of voltage maps immediately after PFA and at a median of 84 days (interquartile range 69–90 days) later revealed that there was no significant difference in either the left- and right-sided PV antral isolation areas or nonablated posterior wall area. The distances between low-voltage edges on the posterior wall were also not significantly different between the 2 time points.
This study demonstrates that the level of PV antral isolation after PFA with a multielectrode PFA catheter persists without regression.
Recurrent Atrial Fibrillation After Cryoballoon Ablation: What to Expect!
2020, Cardiac Electrophysiology Clinics

View all citing articles on Scopus

: Supported in part by the Deane Institute for AF and Stroke Research, and an NIH K23 award (HL68064) to Dr. Reddy. Drs. Reddy and Neuzil have received research grant support from Cryocath Technologies, Inc, Cardiofocus, Inc, Biosense-Webster, Inc, and St Jude Medical, Inc. Dr. Kim is an employee of St Jude Medical, Inc.

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Original-clinicalBalloon catheter ablation to treat paroxysmal atrial fibrillation: What is the level of pulmonary venous isolation?

Background

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

J Am Coll Cardiol

J Am Coll Cardiol

Heart Rhythm

J Am Coll Cardiol

Heart Rhythm

Electrophysiological end point for catheter ablation of atrial fibrillation initiated from multiple pulmonary venous foci

Circulation

Ablation therapy for atrial fibrillation (AF): Past, present and future

Cardiovasc Res

Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation

Circulation

Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation

Circulation

Clinical outcome after radiofrequency catheter ablation of focal atrial fibrillation triggers

J Cardiovasc Electrophysiol

Complete isolation of left atrium surrounding the pulmonary veins: New insights from the double-lasso technique in paroxysmal atrial fibrillation

Circulation

Original-clinical
Balloon catheter ablation to treat paroxysmal atrial fibrillation: What is the level of pulmonary venous isolation?