ClinicalAblationCryoballoon temperature predicts acute pulmonary vein isolation
Introduction
Cryoballoon technology is increasingly used to perform pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF).1, 2, 3, 4 The device is designed to create circumferential lesions around the target PV, ideally with a single cryoballoon application (CBA). However, cryoablation vitally depends on balloon-tissue contact or pulmonary vein (PV) occlusion, because residual blood flow interferes with lesion formation. In addition, complete PV occlusion reduces surrounding blood flow, resulting in lower cryoballoon temperatures.5 Failure to achieve complete balloon-tissue contact results in ineffective CBA. Because CBA is performed for 4 to 5 minutes, repeated ineffective CBA prolongs procedure duration. Different techniques to evaluate PV occlusion have been proposed, some of which require additional diagnostic tools such as intracardiac ultrasound.5, 6, 7, 8 The simplest and most widely used technique is angiography via the balloon tip.1, 2, 3, 4 Angiography, however, cannot be used to evaluate contact during freezing, and it has been shown that balloon dislocation may occur after initiation of CBA.5
Cryoballoon temperature (CBT) is measured continuously during CBA by a thermocouple in the proximal inner balloon (Figure 1). We hypothesized that CBT, a readily available parameter during cryoballoon PVI, may be used to discriminate between effective and ineffective CBA during freezing.
Section snippets
Patients
Between April 2006 and March 2010, a total of 134 patients underwent cryoballoon PVI using the single big cryoballoon technique.1 In 66 of these patients, complete recordings of CBT over time during each CBA was available. These patients constitute the study population. Baseline clinical characteristics are shown in Table 1.
Cryoballoon ablation
The concept of the single big cryoballoon technique for PVI (Arctic Front, 28-mm diameter, Medtronic CryoCath LP, Pointe-Claire, Quebec, Canada) has been described in detail
Cryoballoon ablation
PV anatomy consisted of 4 individual PVs in 60 patients. In the remaining 6 patients, a left common PV was found (Table 2). In 5 of these patients with a short common trunk, superior and inferior branches were isolated individually and included in the temperature analysis as left superior PV and left inferior PV, respectively. In 1 patient, the left common PV was isolated by sequentially performing CBA at the superior and inferior circumference and omitted from temperature analysis. Of a total
Discussion
The main findings of this study are as follows. (1) Cryoballoon temperature may be used to discriminate between successful and failed CBA at various time points during freezing. (2) A high CBT predicted a failed freeze with high specificity. (3) Very low CBT was invariably associated with successful PVI.
Although the ideal freezing duration of a CBA remains to be determined, cryoballoon ablation is generally performed for 4 to 5 minutes.1, 2, 3, 4, 9 During this period, the operator is usually
Conclusion
CBT, a simple parameter provided by the cryoballoon system, may be used to discriminate between successful and failed PVI at various time points during freezing. Cutoff temperatures were defined that predicted failed ablation during freezing with high specificity. CBT may be used to guide cryoablation and avoid prolonged inefficient freezing.
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2020, Heart Rhythm O2Citation Excerpt :Using the first-generation cryoballoon, the temperature at 120 seconds after ablation initiation was used to predict lesion durability. In these series, temperatures warmer than –36°C for superior PVs and warmer than –33°C for inferior PVs predicted ineffective PVI with >95% specificity (positive predictive value 80% for superior PVs and 82% for inferior PVs).22,23 As such, we consider lesions that fail to achieve a temperature colder than –35°C after 60 seconds ineffectual.24,25
K. H. Kuck is a consultant for Cryocath and received research grant and honoraria for Medtronic educational lectures. A. Fürnkranz and J. Chun received honoraria payments for Medtronic educational lectures.