Persistence of an iatrogenic atrial septal defect after a second-generation cryoballoon ablation of atrial fibrillation

Heart failure caused by iatrogenic atrial septal defect after cryoballoon ablation for atrial fibrillation

An 83-year-old man with no structural heart disease underwent pulmonary vein isolation (PVI) for symptomatic paroxysmal atrial fibrillation (AF). The PVI was successfully performed by cryoballoon ablation with a single transseptal puncture. A 12Fr deflectable sheath and an 8.5Fr long sheath crossed the interatrial septum via the same puncture site. Five months after PVI, the patient was readmitted because of heart failure and recurrence of AF. The echocardiogram showed a large (10.7 × 5.8 mm) iatrogenic atrial septal defect (IASD) at the previous puncture site. Both right-to-left and left-to-right shunts were observed during systole and diastole, respectively. Despite the initiation of optimal medical therapy for heart failure, symptoms were not completely controlled and IASD remained 11 months after PVI. Eventually, he received multiple additional PVI for recurrence of AF and percutaneous transcatheter closure (13 mm disc for 10.9 × 8.9 mm- IASD), then heart failure was controlled with the improvement of the right atrial and ventricular size. Although the induction of heart failure by IASD after PVI is rare, it should be noted as one of the causes, especially after cryoballoon ablation with simultaneous mapping catheter insertion via a single transseptal puncture. <Learning objective: Pulmonary vein isolation (PVI) is the established therapy for atrial fibrillation; however, it may cause several complications including iatrogenic atrial septal defect (IASD). IASD is less apparent than other complications, therefore it may be underrecognized. Although the induction of heart failure by IASD after PVI is rare, it should be noted as one of the causes, especially after cryoballoon ablation with simultaneous circular mapping catheter insertion via a single transseptal puncture.>.

Cryoballoon pulmonary vein isolation as a standard approach for interventional treatment of atrial fibrillation. A review and a practical guide to an effective and safe procedure

Since the cryoballoon was introduced into clinical practice, approximately half a million patients have undergone a pulmonary vein isolation (PVI) using this tool throughout the world. This single-shot technique makes the pulmonary vein isolation procedure easier and has the potential to expand access to the interventional treatment of atrial fibrillation (AF), eventually leading to a reduction of the AF-related disease burden. Several studies and metanalyses have assessed the acute and long-term efficacy of cryoballoon-based PVI. The reported success rate of PV isolation during the procedure is about 98%. Despite this, the long-term effectiveness of the procedure (AF free survival) assessed at 1 year after the ablation is in the range of 70-82%. The AF-free survival rate significantly depends on the clinical characteristics of the studied group and the presence of risk factors, especially the type of AF (paroxysmal vs. persistent), LA size and the presence of heart failure. For a safe and effective procedure the electrophysiologist should be aware of all minute details of the procedure including several tricks developed by the most experienced operators and the pre-procedural and post-procedural management recommendations. Detailed knowledge of complications of cryoballoon (CB)-based ablation is mandatory. This review concentrates on the practical aspects and recommendations for a cryoballoon ablation procedure. The review is based on the authors' experience, including 800 procedures performed over 11 years with a low complication rate, and is presented within the context of the literature.

Treatment Complications of Atrial Fibrillation and Their Management

Atrial fibrillation (AF) is a rhythm disturbance defined by irregular, rapid electrical, and mechanical activation of the atria, which causes unsynchronized atrial contraction and promotes thromboembolism. AF is the most common sustained arrhythmia. Its prevalence and incidence are increasing due to aging and improved survival from acute heart diseases. This article is a review on AF management from both a surgical and catheter-based perspective. While both treatment approaches to AF have been shown to be successful in the management of AF, they are not without their own inherent complications. This article seeks to review some of these complications and help to guide treatment.

Prospective evaluation of iatrogenic atrial septal defect after cryoballoon or radiofrequency catheter ablation of atrial fibrillation-"EVITA" study

PURPOSE

Iatrogenic atrial septal defect (IASD) after catheter ablation (CA) for atrial fibrillation (AF) due to transseptal puncture (TSP) can occur. The aim of this prospective study was to describe the incidence of IASD and to detect any cerebrovascular accident (CVA) after radiofrequency (RF) and cryoballoon (CB) CA.

METHODS

Between July 2014 and September 2016, 94 patients (pts) (RF; 48, CB; 46, 30 (31.9%) women, mean age = 60 ± 9.7 years) with paroxysmal AF were enrolled who underwent CA procedure for the first time. During RF ablation a single (n = 30, 62.5%) or double (n = 18, 37.5%) TSP was performed. Transoesophageal echocardiography before the procedure and at the 3-month and 12-month follow-up (FU) was accomplished. During the FU period, we evaluated the occurrence of any postprocedural CVA.

RESULTS

At the 3-month FU, IASD was detected in 17/94 (18.1%) pts; in 9/48 (18.8%) pts in the RF while in 8/46 (17.4%) pts in the CB group (p = 0.866), all of them with left-to-right shunt. In the RF group, 6/30 (20%) pts with a single TSP while 3/18 (16.7%) pts in the double TSP group had IASD (p = 0.780). 14/17 (82.4%) IASDs showed high spontaneous closure rate at the 12-month FU. None of the pts died or suffered from CVA.

CONCLUSION

Persistent IASD can occur rather frequently following AF CA. No significant difference was observed between the RF and CB techniques concerning the presence of IASD at 3-month. IASDs showed a high spontaneous closure rate. No cerebral thromboembolic event was observed in the 12-month FU period.

Evasion maneuver for transseptal approach during cryoballoon pulmonary vein isolation

Purpose

Pulmonary vein isolation (PVI) is a cornerstone therapy in patients with symptomatic atrial fibrillation. One current method is performing a PVI using a cryoballoon (CB). The CB is inserted into the left atrium via a steerable sheath. However, at times, passing of the interatrial septum by the sheath is hindered, e.g., due to septal fibrosis. Here we report our experience with an evasion maneuver to facilitate this approach using a 6F multipolar and steerable coronary Sinus catheter (CS) for predilatation of the interatrial septum.

Methods and results

We report 10 patients undergoing a CB-PVI, where the investigator experienced difficulties in passing the interatrial septum with the CB sheath. In these cases, after three conventional abortive attempts, we predilated the transseptal puncture site using both the CS catheter and the dilatator of the CB sheath. Thereafter access of the CB sheath to the left atrium could be achieved instantly and without further resistance.

Conclusion

We report a safe and feasible maneuver to facilitate transseptal access with the CB steerable sheath in cases complicated by excessive interatrial resistance.