Atrial fibrillation ablation using cryoballoon technology: Recent advances and practical techniques

Abstract

Atrial fibrillation (AF) affects 1-2% of the population, and its prevalence is estimated to double in the next 50 years as the population ages. AF results in impaired patients' life quality, deteriorated cardiac function, and even increased mortality. Antiarrhythmic drugs frequently fail to restore sinus rhythm. Catheter ablation is a valuable treatment approach for AF, even as a first-line therapy strategy in selected patients. Effective electrical pulmonary vein isolation (PVI) is the cornerstone of all AF ablation strategies. Use of radiofrequency (RF) catheter in combination of a three-dimensional electroanatomical mapping system is the most established ablation approach. However, catheter ablation of AF is challenging even sometimes for experienced operators. To facilitate catheter ablation of AF without compromising the durability of the pulmonary vein isolation, "single shot" ablation devices have been developed; of them, cryoballoon ablation, is by far the most widely investigated. In this report, we review the current knowledge of AF and discuss the recent evidence in catheter ablation of AF, particularly cryoballoon ablation. Moreover, we review relevant data from the literature as well as our own experience and summarize the key procedural practical techniques in PVI using cryoballoon technology, aiming to shorten the learning curve of the ablation technique and to contribute further to reduction of the disease burden.

Modified hockey stick maneuver utilizing a steerable cryoballoon catheter for left inferior pulmonary vein isolation

“…4 In LIPV isolation, the HSM is often applied to occlude the LIPV ostium. [1][2][3] In the HSM for complete LIPV occlusion, a steerable seg- This case demonstrates that the modified HSM using a steerable cryoballoon catheter might be considered as an option when the standard one using a steerable sheath is not operated as the cryoballoon occlusion technique for LIPV isolation.…”

“…The favorable outcome of cryoballoon PV isolation is associated with optimal PV occlusion by wedging of the inflated cryoballoons . In LIPV isolation, the HSM is often applied to occlude the LIPV ostium . In the HSM for complete LIPV occlusion, a steerable segment of the sheath crossing the fossa ovalis should be positioned in the LA to optimize the coaxial arrangement of the cryoballoon shaft and the LIPV, as well as to push the wedged cryoballoon toward the LIPV ostium.…”

“…The position of the cryoballoon shaft coaxial to the LIPV was confirmed in the left anterior oblique view during the maneuver, but the steerable segment of the sheath was pushed out of the LA, rendering the inflated cryoballoon position unsuitable for LIPV occlusion (Figure ). Even using a direct approach as well as a pull‐down technique using the steerable sheath, LIPV occlusion could not be obtained. Therefore, following retraction of the steerable sheath with restoration of the deflection in its straight configuration, the steerable cryoballoon catheter was deflected and advanced over the mapping catheter toward the LIPV ostium, thus accomplishing LIPV occlusion that was confirmed by venogram.…”

Synergy of pulmonary vein isolation and catheter renal denervation in atrial fibrillation complicated with uncontrolled hypertension: Mapping the renal sympathetic nerve and pulmonary vein (the pulmonary vein isolation plus renal denervation strategy)?

“…While PVI has been well recognized as an established ablation approach with clear endpoint using either radiofrequency or cryoenergy in treating AF, RDN currently on the other hand remains at a stage of “blinded ablation.” Several factors such as patient selection, baseline BP patterns, antihypertensive medications, comorbidities, ablation devices, and acute BP response have been reported to be related to the response of RDN . At technique level, electrical stimulation at intraluminal renal artery using electrical catheter aiming at inducing BP elevation measured before and after the ablation procedure has been used to assess the extent of denervation .…”

“…While PVI has been well recognized as an established ablation approach with clear endpoint using either radiofrequency or cryoenergy in treating AF, 51,52 RDN currently on the other hand remains at a stage of "blinded ablation." 53 level, electrical stimulation at intraluminal renal artery using electrical catheter aiming at inducing BP elevation measured before and after the ablation procedure has been used to assess the extent of denervation.…”