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. 2024 Jan-Feb;24(1):1-5.
doi: 10.1016/j.ipej.2023.11.002. Epub 2023 Nov 17.

Multi-catheter cryotherapy for the treatment of resistant accessory pathways

Lisa Wm Leung  1 , Banu Evranos  1 , Hanney Gonna  1 , Idris Harding  1 , Giulia Domenichini  1 , Mark M Gallagher  2
Affiliations

Multi-catheter cryotherapy for the treatment of resistant accessory pathways

Lisa Wm Leung et al. Indian Pacing Electrophysiol J. 2024 Jan-Feb.

Abstract

Objective: To investigate the utility of simultaneous multi-catheter cryotherapy for the treatment of APs that were previously resistant to standard radiofrequency (RF) catheter ablation.

Background: Catheter ablation is established in the treatment of accessory pathways (AP), with high rates of permanent procedural success with a single attempt. However, there are still instances of acute procedural failure and AP recurrences with standard RF and cryotherapy methods.

Methods: Seven consecutive cases of pre-excitation syndromes with prior failed RF catheter ablation had the novel treatment. Cryotherapy was delivered using two 8 mm tip focal cryoablation catheters (Freezor® Max, Medtronic, Minneapolis, Minnesota, USA).

Results: Accessory pathway localisation was septal in 5 cases, left posterolateral in 1, right lateral in 1. In all cases, ablation of the AP was acutely successful with no procedural complications. Median procedure and fluoroscopy durations were 199 and 35 min, sequentially. Median Procedure duration fell significantly in the second half of series (174 min) compared to the first half (233 min, P = 0.05). One patient had evidence of a recurring AP conduction with pre-excitation at 5-week follow up. After a median follow up of 66.8+-6.5 months, 6 out of 7 patients remained asymptomatic and free of pre-excitation.

Conclusion: Simultaneous multi-catheter cryotherapy is feasible, safe and can provide definitive cure of accessory pathways that were previously resistant to standard radiofrequency ablation. Further study is required in the assessment of this novel form of advanced cryotherapy to treat complex and resistant arrhythmias.

Keywords: Accessory pathway; Catheter ablation; Cryoablation; Pre-excitation; Wolff Parkinson white syndrome.

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Conflict of interest statement

Declaration of competing interest Dr Gallagher has received research funding from Attune medical and has acted as a consultant and paid speaker for Biosense Webster. No other author has any conflict of interest.

Figures

Fig. 1
Fig. 1
Dual catheter cryotherapy of a left lateral concealed accessory pathway (case 4). After a normal baseline coronary sinus (panel A), the site of earliest atrial activation in tachycardia was mapped via a transseptal approach (panel B, catheter arrowed). Pathway block was achieved at 12 s from the occurrence of a cryotherapy artefact (right hand panel). The second Freezor Max was brought close to the same site, within the coronary sinus and therapy was delivered simultaneously. Additional cryotherapy was delivered with the second catheter at different sites both within the coronary sinus and endocardially (panel C).
Fig. 2
Fig. 2
Dual catheter cryotherapy of a left paraseptal pathway. A baseline coronary sinus showed no abnormality (panel A). Delivery of cryotherapy through the Freezor Max ablation catheter in the proximal coronary sinus resulted in an apparent loss of pre-excitation at 2.4 s from the start of cryotherapy artefact (right hand panel). The apparent loss of pre-excitation is due to a junctional rhythm, but when sinus rhythm re-emerged, it was without pre-excitation. The second cryocatheter was used to deliver simultaneous therapy endocardially close to the site of the first catheter (panel B), and then at adjacent sites in multiple subsequent deliveries.
Fig. 3
Fig. 3
Dual catheter cryotherapy of a right free wall accessory pathway. This manifest pathway (case 6) was mapped to a right free wall location using a Freezor Max catheter (arrow) delivered via a 10F Arrive sheath (Medtronic). The second cryocatheter was brought to an adjacent position, using the first catheter for support; multiple deliveries were performed with both catheters simultaneously.
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