Balloon occlusion of the distal coronary sinus facilitates mitral isthmus ablation

Wong, Kelvin C.K.; Jones, Michael A.; Qureshi, Norman; Sadarmin, Praveen P.; Bono, J de; Rajappan, Kim; Bashir, Yaver; Betts, Timothy R.

doi:10.1016/j.hrthm.2011.01.042

Cited by 38 publications

(52 citation statements)

References 33 publications

(39 reference statements)

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“…It was recently shown in humans that balloon occlusion of the CS during mitral isthmus ablation decreased ablation time and the need for CS ablation to achieve block, supporting the hypothesis that a "heat sink" is an obstacle to successful permanent MI ablation. 19 Another possible reason for the higher recovery rate of conduction at the MI as compared with the CTI is failure to achieve transmural lesions due to the lower power settings, for safety reasons, used in the left atrium as compared with the right atrium. Jaïs et al reported cardiac tamponade in 4% of patients undergoing MI ablation for AF.…”

Section: Discussionmentioning

confidence: 99%

Recovery of Mitral Isthmus Conduction Leads to the Development of Macro-Reentrant Tachycardia After Left Atrial Linear Ablation for Atrial Fibrillation

Sawhney

Anand

Robertson

et al. 2011

Circ: Arrhythmia and Electrophysiology

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Background-Left atrial linear ablation for atrial fibrillation (AF) may be proarrhythmic, leading to left atrial macro-reentrant tachycardia (LAT). Whether due to failure to achieve block initially or to recovery of conduction after ablation is unknown. This study was designed to evaluate the frequency of recovery of mitral isthmus (MI) conduction compared with cavo-tricuspid isthmus (CTI) conduction, and the relationship between recovery of MI conduction and postablation LAT. Methods and Results-Of 163 patients with AF who underwent circumferential pulmonary vein ablation plus left atrial linear ablation, in whom MI and CTI ablation produced bidirectional conduction block, 52 underwent repeat ablation for recurrent atrial arrhythmias (AF or LAT). Of these 52 patients, coronary sinus ablation was required in 48 to achieve bidirectional MI block at the index ablation. During repeat ablation, MI and CTI conduction was assessed in sinus rhythm. At repeat ablation, MI conduction had recovered in 38 of 52 patients, as compared with CTI conduction which recovered in only 12 of 52 patients (Pϭ0.001). At repeat ablation, the recurrent clinical arrhythmia in 12 patients was MI-dependent LAT. Recovery of MI conduction was associated with development of MI-dependent LAT (Pϭ0.01). Conclusions-Despite using bidirectional conduction block as a procedural end point, recovery of MI conduction is common and may lead to LAT after left atrial linear ablation for AF. The reason for greater recovery of MI versus CTI conduction is unknown but could be due to differences in isthmus anatomy or lower power used for ablation in the left versus right atrium. (Circ Arrhythm Electrophysiol. 2011;4:832-837.)

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Section: Discussionmentioning

confidence: 99%

Recovery of Mitral Isthmus Conduction Leads to the Development of Macro-Reentrant Tachycardia After Left Atrial Linear Ablation for Atrial Fibrillation

Sawhney

Anand

Robertson

et al. 2011

Circ: Arrhythmia and Electrophysiology

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“…However, the achievement of a complete isthmus block remains difficult. The occlusion of the segment of CS with a balloon to prevent a heat sink has been shown to facilitate the creation of a mitral isthmus block but is currently not widely employed in clinical practice [117,378]. The roof line connecting both superior PVs is usually easier than the mitral isthmus line.…”

Section: Strategies Tools and Endpoints For The Creation Of Linear mentioning

confidence: 99%

2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design

Calkins

Kuck

Cappato

et al. 2012

J Interv Card Electrophysiol

1,464

680

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This is a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation, developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology and the European Cardiac Arrhythmia Society (ECAS), and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). This is endorsed by the governing bodies of the ACC Foundation, the AHA, the ECAS, the EHRA, the STS, the APHRS, and the HRS.

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“…Balloon occlusion of CS facilitates formation of transmural lesion from the endocardium and curtails the need for epicardial ablation. 1,2 We recorded an epicardial-only block within 3 minutes of endocardial mitral isthmus ablation. Such rapid attainment of epicardial block can be explained by the fact that the epicardial muscle sleeve enveloping the distal CS is thin, making it susceptible to ablation faster than the relatively thicker musculature of the contiguous endocardial left atrium, 3 especially when the elimination of epicardial heat sink facilitates formation of transmural lesion from the endocardium.…”

mentioning

confidence: 99%

Epicardial-Only Block During Endocardial Mitral Isthmus Ablation Facilitated by Coronary Sinus Occlusion

Wilton

Scherr

Hocini

et al. 2011

Circ: Arrhythmia and Electrophysiology

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A 60-year-old man with obesity and severe left ventricular dysfunction and left atrial dilatation underwent catheter ablation of symptomatic, drug-refractory, persistent atrial fibrillation. After pulmonary vein isolation and electrogrambased ablation, atrial fibrillation was cardioverted successfully. Mitral isthmus ablation was undertaken during distal coronary sinus (CS) 1 to 2 pacing. CS blood flow was occluded by inflating a 1-cm spherical balloon distally. During ongoing radiofrequency application using an irrigated ablation catheter (average power, 34 W; temperature, 39°C) on the endocardial mitral isthmus line, conduction delay between the bipoles CS 1 to 2 (pacing site) and CS 3 to 4 jumped suddenly from 22 to 168 ms, indicating local block within the CS (epicardial) (Figure). The CS activation pattern immediately changed from distal to proximal at baseline to proximal to distal after the block (Figure). The conduction along the corresponding endocardial (left atrial) side (arrows) was not affected (not blocked). The latter was assessed from the far-field left atrial potentials recorded on the CS bipoles (Figure). Notably, only 165 s of endocardial radiofrequency application was made before the moment of epicardial block.Mitral isthmus ablation is challenging. CS blood flow acts as a "heat sink" precluding transmural lesion formation during endocardial ablation. Consequently, epicardial radiofrequency application from inside the CS frequently is necessary. Balloon occlusion of CS facilitates formation of transmural lesion from the endocardium and curtails the need for epicardial ablation. 1,2 We recorded an epicardial-only block within 3 minutes of endocardial mitral isthmus ablation. Such rapid attainment of epicardial block can be explained by the fact that the epicardial muscle sleeve enveloping the distal CS is thin, making it susceptible to ablation faster than the relatively thicker musculature of the contiguous endocardial left atrium, 3 especially when the elimination of epicardial heat sink facilitates formation of transmural lesion from the endocardium. Mitral isthmus was transmurally blocked after 16 minutes of endocardial radiofrequency application. Epicardial ablation was not required. There were no complications from 25 minutes of CS occlusion. DisclosuresNone. References1. Shah AJ, Nault I, Miyazaki S, Jadidi AS, Forclaz A, Rivard L, Xhaet O, Linton N, Liu X, Derval N, Sacher F, Jaïs P, Haïssaguerre M, Hocini M. Mitral isthmus ablation with temporary coronary sinus occlusion to prevent tissue cooling by venous flow. Heart Rhythm. 2010;7:S153. 2.

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Balloon occlusion of the distal coronary sinus facilitates mitral isthmus ablation

Cited by 38 publications

References 33 publications

Recovery of Mitral Isthmus Conduction Leads to the Development of Macro-Reentrant Tachycardia After Left Atrial Linear Ablation for Atrial Fibrillation

Recovery of Mitral Isthmus Conduction Leads to the Development of Macro-Reentrant Tachycardia After Left Atrial Linear Ablation for Atrial Fibrillation

2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design

Epicardial-Only Block During Endocardial Mitral Isthmus Ablation Facilitated by Coronary Sinus Occlusion

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