How to Prevent, Detect and Manage Complications Caused by Cryoballoon Ablation of Atrial Fibrillation

The efficacy and safety of cryoballoon atrial fibrillation ablation in patients with heart failure: A systematic review and meta-analysis

INTRODUCTION

While atrial fibrillation (AF) ablation has proven beneficial for heart failure (HF) patients, most reports were performed with radiofrequency ablation. We aimed to evaluate the efficacy and safety of cryoballoon AF ablation in patients with HFrEF.

METHOD

We comprehensively searched the databases of MEDLINE, EMBASE, and Cochrane database from inception to December 2022. Studies that reported the outcomes of freedom from atrial arrhythmia, complications, NYHA functional class (NYHA FC), and left ventricular ejection fraction (LVEF) after Cryoballoon AF ablation in HF patients were included. Data from each study were combined with a random-effects model.

RESULT

A total of 9 studies observational studies with 1414 HF patients were included. Five studies had only HF with reduced ejection fraction (HFrEF), 1 study with HF with preserved ejection fraction (HFpEF), and others with mixed HF types. Freedom from AA in HFrEF at 12 months was 64% (95% CI 56-71%, I2 58%). There was a significant improvement of LVEF in these patients with a standard mean difference of 13% (95% CI 8.6-17.5%, I2 99% P < 0.001. The complication rate in HFrEF group was 6% (95% CI 4-10%, I2 0%). The risk of recurrence of atrial arrhythmia was not significantly different between HF and no HF patients (RR 1.34, 95% CI 0.8-2.23, I2 76%).

CONCLUSION

Cryoballoon AF ablation is effective in HFrEF patients comparable to radiofrequency ablation. The complication rate was low.

Esophageal injury, perforation, and fistula formation following atrial fibrillation ablation

BACKGROUND

Esophageal perforation and fistula formation are rare but serious complications following atrial fibrillation ablation. In this review article, we outline the incidence, pathophysiology, predictors, and preventative strategies of this dreaded complication.

METHODS

We conducted an electronic search in 10 databases/electronic search engines to access relevant publications. All articles reporting complications following atrial fibrillation ablation, including esophageal injury and fistula formation, were included for systematic review.

RESULTS

A total of 130 manuscripts were identified for the final review process. The overall incidence of esophageal injury following atrial fibrillation ablation was significantly higher with thermal ablation modalities (radiofrequency 5-40%, cryoballoon 3-25%, high-intensity focused ultrasound < 10%) as opposed to non-thermal ablation modalities (no cases reported to date). The incidence of esophageal perforation and fistula formation with the use of thermal ablation modalities is estimated to occur in less than 0.25% of all atrial fibrillation ablation procedures. The use of luminal esophageal temperature monitoring probe and mechanical esophageal deviation showed protective effect toward reducing the incidence of this complication. The prognosis is very poor for patients who develop atrioesophageal fistula, and the condition is rapidly fatal without surgical intervention.

CONCLUSIONS

Esophageal perforation and fistula formation following atrial fibrillation ablation are rare complications with poor prognosis. Various strategies have been proposed to protect the esophagus and reduce the incidence of this fearful complication. Pulsed field ablation is a promising new ablation technology that may be the future answer toward reducing the incidence of esophageal complications.

Perforation of the Pulmonary Vein During Ablation of Atrial Fibrillation: A Rare Complication of Cryoballoon Ablation

A 58-year-old man admitted for a cryoballoon ablation due to a history of symptomatic paroxysmal atrial fibrillation experienced pericardial effusion and cardiac tamponade intraoperatively. A longitudinal left superior pulmonary vein perforation was confirmed by emergency thoracotomy and repaired. He developed atrial fibrillation 2 days postoperatively, which was terminated with colchicine and oral steroids the following day.

Adverse events in cryoballoon ablation for pulmonary vein isolation: Insight from the Food and Drug Administration Manufacturer and User Facility Device Experience

Background

Real-world clinical data on the adverse events related to the use of cryoballoon catheter for pulmonary vein isolation remains limited.

Objective

To report and describe the adverse events related to the use of Artic Front cryoballoon catheters (Arctic Front, Arctic Front Advance, and Arctic Front Advance Pro) reported in the Food and Drug Administration's (FDA) Manufacturers and User Defined Experience (MAUDE) database.

Methods

We reviewed all the adverse events reported to the FDA MAUDE database over a 10.7-year study period from January 01, 2011 to September 31, 2021. All events were independently reviewed by two physicians.

Results

During the study period, a total of 320 procedural-related adverse events reported in the MAUDE database were identified. The most common adverse event was transient or persistent phrenic nerve palsy (PNP), accounting for 48% of all events. This was followed by cardiac perforation (15%), pulmonary vein stenosis (8%), transient ischemic attack or stroke (6%), vascular injury (4%), transient or persistent ST-elevation myocardial infarction (3%), hemoptysis (2%), pericarditis (2%), and esophageal ulcer or fistula (1%). There were six reported intra-procedural death events as a result of cardiac perforation.

Conclusion

The two most common procedural adverse events associated with cryoballoon ablation were PNP and cardiac perforation. All cases of procedural mortality were due to cardiac perforation.

Efficacy and safety of same-day discharge after atrial fibrillation ablation: A systematic review and meta-analysis

Conventionally, patients have been admitted overnight after atrial fibrillation (AF) catheter ablation. Several centers have recently adopted a same‐day discharge (SDD) protocol for patients undergoing AF catheter ablation. We aimed to systematically review the current evidence for the safety and efficacy of SDD after AF catheter ablation. A systematic search was performed in PubMed, Embase, Scopus, Web of Science, and the Cochrane library until August 21, 2021. The risk of bias was assessed with the “Methodological Index for Non‐Randomized Studies” (MINORS). The pooled efficacy rate of SDD protocol (defined as the proportion of patients discharged the same day of ablation among the patients who were planned for SDD) was calculated. Meanwhile, pooled major complication rates and early readmission or emergency department (ED) visit rates were evaluated in successful and planned SDD groups separately. Overall, 12 observational studies consisting of 18,065 catheter ablations were included, among which 7320 (40.52%) were discharged the same‐day after ablation. The pooled efficacy was 90.3% (95% confidence interval [CI] [82.7–96.0]). The major complication rates were 1.1% (95%CI [0.5–1.9]), and 0.7% (95% CI [0.0–3.1]) in planned SDD and successful SDD groups, respectively. In addition, readmission/ED visit rate were 3.0% (95%CI [0.9–6.1]), and 3.1% (95% CI [0.8–6.5]) in the same groups. There were no significant differences between planned SDD and overnight groups with respect to major complication rate (risk ratio = 0.70, 95%CI [0.35–1.42], p‐value = .369). The available data indicates that SDD after AF ablation is safe and efficient. Further prospective and randomized studies are warranted to elucidate the safety of SDD after AF ablation and develop a standardized SDD protocol.

New Minimally Invasive and Tailor-Made Strategy for Cryoballoon Ablation in Patients With Paroxysmal Atrial Fibrillation

BACKGROUND

The optimal dosage for cryoballoon ablation (CBA) of atrial fibrillation (AF) is still unknown.

OBJECTIVE

This study aimed to evaluate the clinical implications of a reduction in the freezing duration to <180 seconds during CBA guided by the time to the target temperature.

METHODS

This study enrolled 325 consecutive paroxysmal AF patients who underwent CBA. It was a retrospective observational study in a single centre. It compared 164 patients who underwent a tailor-made CBA procedure (group T) with 161 who had a standard CBA procedure (group S). In group T, the freezing duration was reduced to 150 seconds when the temperature reached ≤ -40 °C within 40 seconds. Furthermore, it was reduced to 120 seconds when it reached ≤ -50 °C within 60 seconds. In the other patients, the freezing duration was 180 seconds, except for excessive freezing of ≤ -60 °C and/or emergent situations while monitoring the oesophageal temperature, and for phrenic nerve injury, as in group S.

RESULTS

In group T, 89 patients (83%) underwent CBA with a reduction in the freezing duration. The total freezing time for each pulmonary vein was significantly shorter in group T than group S, and the total procedure time in group T decreased by an average of 4 minutes compared with group S. The rate of requiring additional radio frequency ablation following the CBA was significantly lower in group T than group S. The AF-free survival rate during the follow-up period (median, 366 days) was similar between the two groups.

CONCLUSION

The safety and efficacy of the new CBA strategy were non-inferior to the standard procedure.

Atrioesophageal fistula after atrial fibrillation catheter ablation: A case report

RATIONALE

Atrioesophageal fistula (AEF) is a rare but serious complication of atrial fibrillation (AF) catheter ablation with associated high mortality rates.

PATIENT CONCERNS

A 42-year-old male patient who underwent catheter ablation in local hospital 20 days ago because of persistent AF was admitted to our Emergency Room with unconsciousness and high axillary temperature and white blood cell count. Craniocerebral CT scan found multiple infarct lesions in both frontal and occipital lobes. Pneumatosis between the left atrium and the esophagus was observed in the chest CT.

DIAGNOSES

AEF.

INTERVENTIONS

We performed a salvage operation of the left atrium debridement, and left atrium patch repairing under extracorporeal circulation. We opened the mediastinum, and dissected the esophageal perforation. A special irrigating catheter with multiple side ports on the tip was placed from the esophagus to the posterior mediastinum through the esophageal orificium fistulae. We also inserted a gastrointestinal tube to the jejunum under gastroscopy. Three additional drainage tubes were inserted into the esophageal bed and the right thoracic cavity.

OUTCOMES

The procedure was successful. But 7 days later, the patient's family chose to forgo treatment due to multiple cerebral infarcts, respiratory and blood system infection, liver failure, and other complications.

LESSONS

AEF is a rare but fatal complication after catheter ablation. Heightened vigilance is required for early recognition of the AEF. Surgical treatment should be performed as early as possible, especially before the neurological complications occur.

Successful removal of a circular mapping catheter which perforated the pulmonary vein during cryoballoon ablation by lateral thoracotomy: a case report

Background

Serious complications may occur during cryoballoon ablation (CBA). However, pulmonary vein (PV) perforation by a circular mapping catheter and the strategy for removing the catheter remain poorly understood.

Case summary

A 40-year-old male presented with palpitations 2 years ago and was diagnosed with paroxysmal atrial fibrillation 5 months ago. He underwent CBA for paroxysmal atrial fibrillation. After isolation of the left PV, a circular mapping catheter was advanced in the right inferior pulmonary vein (RIPV), and single freeze was performed. After isolation of the PV, the catheter tip was immobile and could not be withdrawn with significant resistance. Computed tomography showed that the catheter tip perforated the posterior basal vein (V10) of the RIPV and remained in the right lower lobe, along with intrapulmonary haemorrhage. The patient underwent surgery via right lateral thoracotomy to remove the catheter. The RIPV was peeled to the periphery to expose the V10. The catheter perforated the vessel wall in the middle of the V10 and entered the pulmonary parenchyma. A microincision on the lung parenchyma covering the surface of the catheter tip was performed, and the circular distal portion of the catheter was cut. The entire catheter (i.e. shaft and proximal portion) was successfully removed from the transseptal catheter.

Discussion

Surgical approach was performed for the management of PV perforation caused by a circular mapping catheter. This case may assist in troubleshooting and problem-solving in case such an event occurs again during procedures in the future.

Cryoballoon Ablation of Atrial Fibrillation in Octogenarians

A significant proportion of AF patients with advanced age are being treated in clinical practice. Cryoballoon ablation of AF, given its shorter procedure time and comparable efficacy to radiofrequency ablation, has rapidly become a commonly used tool for AF ablation. Data regarding the outcomes of cryoballoon ablation of AF in octogenarians are limited because of the exclusion of this age group in the previous studies. The authors report outcomes of 15 octogenarian AF patients undergoing index cryoballoon ablation at a single centre. The mean age of the included patients was 83 ± 3 years. In total, 13 patients (87%) presented with paroxysmal AF, and two (13%) had long-standing persistent AF. At 6 and 12 months of follow-up, freedom from AF was 80% and 70%, respectively. None of the patients suffered any procedure-related complications. Cryoballoon ablation appears to be a safe and effective approach for treating symptomatic AF refractory to antiarrhythmic drug therapy in octogenarian patients, based on outcomes in this cohort. These findings require further validation in prospective randomised studies with larger sample sizes.

Use of a multi-electrode radiofrequency balloon catheter to achieve pulmonary vein isolation in patients with paroxysmal atrial fibrillation: 12-Month outcomes of the RADIANCE study

BACKGROUND

The RADIANCE first-in-man study evaluated acute (3-month) safety and design concept in terms of utility of a new multi-electrode radiofrequency (RF) balloon catheter (HELIOSTAR, Biosense Webster) to achieve pulmonary vein isolation (PVI). After study conclusion, a subset of patients was followed up to 12 months.

METHODS

Patients with drug refractory paroxysmal atrial fibrillation were enrolled. Neurological assessment, cardiac and cerebral magnetic resonance imagings were performed pre and post procedure. Ablation was delivered at 15 Watts to each PV for 60 seconds (electrodes adjacent to the posterior wall limited to 20 seconds). Adenosine or isoproterenol was administered to confirm PVI. Esophageal endoscopy was performed 48 hours post procedure. Patients were clinically followed up for 12 months.

RESULTS

Thirty-nine patients underwent catheter ablation from four centers. Mean age was 60.7 ± 10.0 years with 23 (57.5%) being male. Confirmation of PVI was performed in all PVs treated (152/152). Confirmation of isolation after one delivery was performed solely on 137 of 152 PVs of which 79.6% (109/137) achieved isolation with a single delivery of RF energy. Acute PV reconnection was seen in 4.6% (7/150) of PVs. Freedom from documented atrial arrhythmia at 12 months in those followed up was 86.4% (32/37). A total of 75.7% (28/37) of patients were free from atrial arrhythmia and off antiarrhythmic medications.

CONCLUSION

The HELIOSTAR RF balloon catheter allows for rapid and safe PVI with majority of PVs only requiring one application.

Cryoballoon Ablation for Patients With Paroxysmal Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice and induces cardiac dysfunction and stroke. The development of AF requires a trigger and also an electroanatomic substrate capable of both initiating and perpetuating AF. In the past decade, ectopic beats originating from the pulmonary veins (PV) have been identified as a source of paroxysmal AF. Thus, strategies that target the PV, including the PV antrum, are the cornerstone of most AF ablation procedures. Recently, alternative technologies to radiofrequency catheter ablation for paroxysmal AF such as balloon ablation modalities have been developed. The purpose of this review is to discuss cryoballoon ablation for paroxysmal AF.

Radiofrequency versus cryoballoon ablation for atrial fibrillation: an argument for a 'cryo-first' approach

PURPOSE OF REVIEW

Radiofrequency and cryoballoon ablation are the two most common modalities for catheter ablation of atrial fibrillation. Radiofrequency, being more prevalent and having existed for a longer period, is often utilized for patients' first ablations, despite the efficiency and efficacy of the cryoballoon tool. Here we examine the advantages of the cryoballoon for its use in first-time ablation of atrial fibrillation.

RECENT FINDINGS

The FIRE & ICE trial is established as conclusive evidence of the noninferiority of cryoballoon ablation to radiofrequency ablation in terms of efficacy. Since the study, cryoballoon has evolved in both form and technique, suggesting need for repeat consideration of the advantages of cryoablation over radiofrequency ablation. The second-generation cryoballoon has led to greater efficiency in achieving permanent pulmonary vein isolation, reducing complications, and reducing procedure times.

SUMMARY

There are advantages to the use of cryoballoon which could increase success of first-time ablations, delaying need for repeat procedure and lowering overall burden on patients and the healthcare system. Cryoballoon ablation should be considered for first-time ablation in patients with paroxysmal or persistent atrial fibrillation.

Bronchial Injury - Yet Another Collateral Damage of Cryoablation

With the aging population, the burden of atrial fibrillation is increasing. Cryoablation is a novel technique for pulmonary vein isolation and is considered equally effective as radiofrequency ablation. Some of the known complications of cryoablation include phrenic nerve damage, esophageal injury, pulmonary vein stenosis, new onset atrial flutter, pericardial effusion, and stroke. We present a case of bronchial injury immediately after cryoablation for symptomatic paroxysmal atrial fibrillation. A 67-year-old woman underwent successful pulmonary vein isolation using cryoablation. Her post-operative period was complicated with cough and hemoptysis. During the procedure, she had an extra 3 minutes of freezing of the left inferior pulmonary vein. Her bronchoscopy examination showed blood and erythema in the left main bronchus. She was managed conservatively with cough suppressants and anticoagulation was stopped. Possible etiology of bronchial injury is likely cryoenergy transfer between the pulmonary veins and the bronchus due to their close anatomic proximity. With the increasing use of cryoablation for atrial fibrillation, more cases of bronchial injury will likely be reported in the future. Physicians including electrophysiologist and pulmonologists should be aware of this complication.

Complications of Cryoballoon Pulmonary Vein Isolation

Since the cryoballoon (CB) was introduced into clinical practice, more than 400,000 patients have undergone a pulmonary vein (PV) isolation with a CB throughout the world. Although the efficacy of the first-generation CB was limited, the recently introduced second-generation CB has achieved a greater uniformity in cooling, which has facilitated a shorter time to PV isolation, shorter procedural times, higher rates of freedom from atrial fibrillation and low rates of PV reconnections. Currently, a single short freeze strategy with a single 28 mm balloon has become the standard technique based on the balance of procedural efficacy and safety. However, enhanced cooling characteristics may also result in a greater potential for collateral damage to non-cardiac structures. Knowledge about the potential complications is essential when performing the procedure. In this article, we describe the important complications that should be noted during a CB procedure, and how to minimise the risk of complications based on our experience.