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. 2022 Nov 22;58(12):1700.
doi: 10.3390/medicina58121700.

A Simplified Approach to Pulmonary Vein Visualization during Cryoballoon Ablation of Atrial Fibrillation

Omar Anwar  1   2 , Da-Un Chung  1 , Melanie A Gunawardene  1   2 , Christiane Jungen  2   3 , Jens Hartmann  1   2 , Christian Meyer  4   5 , Nele Gessler  1   2 , Stephan Willems  1   2 , Samer Hakmi  1   2 , Christian Eickholt  1   6
Affiliations

A Simplified Approach to Pulmonary Vein Visualization during Cryoballoon Ablation of Atrial Fibrillation

Omar Anwar et al. Medicina (Kaunas). .

Abstract

Background and Objectives: Selective pulmonary vein (PV) angiography has been established as the gold standard for PV visualization in cryoballoon (CB)-based pulmonary vein isolation (PVI). We sought to simplify this approach to reduce procedural complexity and radiation exposure. Materials and Methods: Patients with paroxysmal and recently diagnosed persistent AF undergoing CB-based PVI from January 2015 to December 2017 were retrospectively analyzed. Patients underwent either selective PV angiography or conventional left atrial (LA) angiography for PV visualization. Results: A total of 336 patients were analyzed. A total of 87 patients (26%) received PV angiography and 249 (74%) LA angiography. LA angiography required fewer cine-sequences for PV visualization, translating into a significant reduction in procedure duration, fluoroscopy time and dose area product. Additionally, less contrast medium was utilized. PV occlusion by the CB, CB temperature and time to isolation showed no significant differences. The number of CB applications and total application time (LA angiography: 1.4 ± 0.02 vs. PV Angiography: 1.6 ± 0.05; p < 0.0001; LA angiography: 297.9 ± 4.62 vs. PV-Angiography: 348.9 ± 11.03; p < 0.001, respectively) per vein were slightly but significantly higher in the PV angiography group. We observed no difference in late AF recurrence (24.7% LA angiography vs. 21.3% PV angiography; p = 0.2657). Conclusions: A simplified protocol, using LA angiography for PV visualization, entails a reduction in procedure time and radiation exposure while equally maintaining procedural efficiency and safety in both groups.

Keywords: angiography; atrial fibrillation; cryoballoon; pulmonary vein isolation.

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Conflict of interest statement

N.G. reports grants from Boston Scientific, grants from Medtronic and support from Bayer Vital outside the submitted work. C.M. reports grants and/or personal fees from Abbott, Biosense Webbster, Biotronik, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Daiichi Sankyo and Medtronic outside the submitted work. S.W. reports grants and personal fees from Abbott, Boston Scientific and Medtronic, and personal fees from Abbott, Boehringer Ingelheim, Bristol Myers Squibb, Bayer Vital, Acutus and Daiichi Sankyo, outside the submitted work. C.E. reports grants and/or personal fees from Abbott, Biosense Webbster, Biotronik, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Daiichi Sankyo and Medtronic outside the submitted work. The remaining authors declare no conflict of interest in relation to this article.

Figures

Figure 1
Figure 1
Left atrial angiography demonstrating the visualization of the pulmonary veins and contour of the left atrium with a single injection of contrast medium. (A): initial injection of contrast dye for the left pumonary veins (dotted lines). (B): Continuation of the initial injection of contrast dye with a counter-clockwise rotation of the SL-0 Sheath further appreciating the anatomy of the left pulmonary veins (dotted lines). (C): Continuation of the initial injection of contrast dye with an additional counter-clockwise rotation now visualizing the right pulmonary veins (dotted lines). The fluoroscopic images were recorded in an anterior-posterior projection (AP). (Also see Supplementary Material).
Figure 2
Figure 2
Left atrial angiography and subsequent occlusion of pulmonary veins (PVs) by cryoballoon (CB) placement, all in anterior-posterior projection. Additionally depicted are the multipolar esophageal temperature probe and the octapolar diagnostic catheter placed in the coronary sinus. (A): Normal anatomy, (B): Left-sided common ostium (LPV) with superior-inferior (LPVs, LPVi) branches; (LSPV: left superior PV, LIPV: left inferior PV, RSPV: right superior PV, RIPV: right inferior PV).
Figure 3
Figure 3
Graphical depiction of the results (PV: pulmonary veins; LA: left atrial angiography).
Figure 4
Figure 4
Survival plot of patients after a mean follow-up of 354 days, showing no significant difference with regard to late recurrence of AF in both groups (after a blanking period of 90 days).
See this image and copyright information in PMC

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