Clin Res Cardiol 101, Suppl 1, April 2012

V1169 - Large antral pulmonary vein isolation by combined cryo-balloon and irrigated radiofrequency catheter ablation in patients with persistent atrial fibrillation
D. Vukajlović1, F. Bourier1, H.-J. Schneider2, K. Kurzidim1
1Klinik für Herzrhythmusstörungen, Krankenhaus Barmherzige Brüder Regensburg, Regensburg; 2Medizinische Klinik III / Kardiologie, Elektrophysiologie, Krankenhaus Barmherzige Brüder Regensburg, Regensburg;
Introduction: Large antral pulmonary vein isolation (PVI) has been shown to be more effective in the treatment of patients with atrial fibrillation (AF) than ostial isolation of individual pulmonary veins (PV). These procedures are time consuming and highly dependent on operator skill. The use of “one-shot” ablation devices, such as cryo-balloons is helpful when ostial PVI is aimed. Deployment of a large cryoballoon may create large antral lesions; however “single big balloon technique” is limited by anatomy. We evaluated the combined use of a big cryo-balloon and irrigated radiofrequency catheter ablation (RFCA) to achieve large antral PVI in patients with persistent AF.
Methods: Patients with symptomatic persistent AF scheduled for PVI were included. Cardiac magnetic resonance imaging (MRI) was performed in all patients prior to ablation. In a subset of patients a novel software allowing 3D-Fluoroscopy by superimposition of MRI derived datasets into biplane fluoroscopy was deployed for planning of ideal ablation lines and documentation of ablation gaps (Figure). The choice of cryo-balloon size was made according to size of either the left superior PV (LSPV) and/or the right superior PV (RSPV), favouring the use of a large, 28 mm balloon in order to achieve large lesions. Completeness of isolation was repeatedly checked with a large diameter (25mm) lasso catheter at the antral ablation site. Gaps after cryo-ballon ablation were closed by RFCA. Areas treated by RFCA were documented and visualized within the 3-D dataset. Patients were followed up after 3, 6 and 12 months.
Results: In our study 54 patients with persistent AF (mean duration 5.1, range 1-60 months) were included.  A 28 mm cryo-balloon was used in 52 patients (96,3%), whereas in the remaining 2 (3.7%) patients a 23mm cryo-balloon was used. In 7 patients (13%) all 4 PVs could be isolated by cryoballon only. After combined cryo-balloon ablation and RFCA, RIPV could not be isolated in 2 and LSPV in 1 patient. Gaps in ablation lines after cryo-balloon ablation were most frequently found on inferior antrum of RIPV (n=27), inferior antrum of LIPV (n=24) and on LSPV/LAA-ridge (n=12). Average procedure duration was 158,7 min and mean fluoroscopy time 38,5 min. There were no major complications. Average duration of RFCA after cryo-balloon ablation was 21,3 minutes. After median FU of 11 months (range 3- 32), 51% of patients were in stable sinus rhythm, free of antiarrhythmics.
Conclusion: The use of a big cryo-balloon does not allow large antral PVI in the vast majority of patients. Adding RFCA however, allows achievement of large antral lesions within a short period of time. RFCA seemed to be highly effective in tissue previously treated by cryo-balloon ablation. The concept of combined cryo-balloon and irrigated RFCA for large antral PVI may combine the strengths of both energy sources. This approach seems to be safe. Planning, guidance and documentation of such an approach can be facilitated by a new software allowing 3D-Flouroscopy.


Figure: Biplane Flouroscopy -30°/60° with 3D-Overlay. Documentation of gaps after cryo-balloon ablation; circumferential antral PV isolation lines are displayed in green (left PVs) and blue (right PVs). Areas of RFCA delivery are depicted as yellow dots in right inferior antrum and red dots in left posterior antrum.

Clin Res Cardiol 101, Suppl 1, April 2012
Zitierung mit Vortrags- oder Posternummer s.o.
DOI 10.1007/s00392-012-1100-6