Persistence of an iatrogenic atrial septal defect after a second-generation cryoballoon ablation of atrial fibrillation

Abstract

Persistent iatrogenic atrial septal defects (iASDs) can be observed after intervention requiring a left atria (LA) access, including pulmonary vein isolation (PVI) of atrial fibrillation (AF). We investigated the incidence of iASDs post-second-generation cryoballoon ablation and the pre-procedural predictors. Eighty-three paroxysmal AF patients underwent PVI using second-generation cryoballoons. The LA was accessed with single 15-Fr steerable sheaths following a radiofrequency transseptal puncture, and the iASD was evaluated with transthoracic echocardiography (TTE), a median of 9.3 (7.1-13.3) months post-procedure. All patients underwent pre-procedural contrast-enhanced multi-detector computed tomography (CT) to evaluate the LA and PV anatomy. iASDs were detected by TTE in 7 (8.4%) patients, a median of 15.5 (6.8-17.3) months post-procedure. Patients with iASDs had significantly larger LA volumes and smaller atrial septal angles, defined as the angle between the atrial septum and sagittal line on the horizontal section at the height of the fossa ovalis, which could be the transseptal puncture site measured on CT, and more likely hypertension than those without. Multivariate analyses revealed that the atrial septal angle was the sole predictor of iASDs [odds ratio 0.764, 95% confidence interval (CI) 0.624-0.935, p = 0.009], and the optimal cut-off value was 57.5° (sensitivity 85.7%, specificity 88.2%, 95% CI 0.873-0.995, p < 0.0001). Patients with iASDs were asymptomatic and had no adverse clinical events during a 17.7 (14.4-25.8) month median follow-up. iASDs were still detectable in 8.4% of patients a median of 15.5 months after the second-generation CB ablation, and the atrial septal angle might aid in predicting persistent iASDs.

Evasion maneuver for transseptal approach during cryoballoon pulmonary vein isolation

“…Recently, Linhart et al [14] reported a relatively high incidence of ASD after CB PVI but without increased clinical complication. This is consistent with other groups’ findings concerning persistent ASD after CB or RF PVI [15], [16], [17]. We report on an evasion maneuver to facilitate transseptal access with the 12F CB sheath (15F outer lumen) in patients undergoing PVI.…”

Treatment Complications of Atrial Fibrillation and Their Management

“…Several case reports and series have been published describing the incidence and clinical implications of an iASD after PV isolation. [45][46][47][48][49][50][51][52] Within these series very few patients required closure of the iASD, suggesting that an iASD is generally benign. In the first report examining the incidence and outcome of iASD after cryoablation specifically, 4 of 13 patients had persistent iASD at 9 months and 1 required closure.…”

Hemodynamically significant iatrogenic atrial septal defects after cryoballoon ablation

“…The defect usually presents with left-to-right shunt owing to the relatively higher left atrial pressure compared to the right atrial pressure but can also present with right-to-left shunt when there is underlying right heart failure or pulmonary hypertension. Several case reports and series have been published describing the incidence and clinical implications of an iASD after pulmonary vein isolation 1, 2, 3, 4, 5, 6, 7, 8. Within these series very few patients required closure of the iASD, suggesting that an iASD is generally benign.…”