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Cryoballoon ablation (CBA) has emerged as a safer alternative to radiofrequency ablation (RFA) of atrial fibrillation (AF). However, fluoroscopy times and contrast media exposure remain a concern with CBA. Intracardiac echocardiography (ICE), which provides anatomy based real time imaging of intracardiac structures, may prove to be helpful in improving the safety and efficacy of the procedure.
Schmidt et al. studied the effects of adding ICE to fluoroscopy in a randomized fashion in patients undergoing cryoballoon based pulmonary vein isolation (PVI) with 28 mm balloon in 43 patients. Twenty-two patients were assigned to ICE + fluoroscopy group (group 1) and 21 patients to fluoroscopy only (group 2). Patients were followed for up to 6 months for any recurrence of AF. During follow up, all the patients underwent clinical evaluation, MRI or CT scan to rule out pulmonary vein stenosis and 48 hour or 7 day Holter monitoring. Primary end point was successful isolation of pulmonary veins and secondary end point were procedural characteristics, complications and recurrence of AF.
There were no significant differences in the baseline patient characteristics. The median procedure time was 130 ± 19 minutes in group 1 compared to 143 ± 27 minutes in group 2 (p = 0.05). Fluoroscopy times (42 ± 13 minutes vs. 26 ± 10 minutes) and requirements for contrast (169 ± 38 ml vs. 88 ± 31 ml) were significantly higher in group 2. Procedural success (isolation of pulmonary veins) was 98 % in both the groups combined. Complications occurred in 3 patients (one minor stroke in group 1 and phrenic nerve palsy in 2 patients in group 2). Mild esophageal erythema occurred in 3 patients (one in group 1 and 2 in group 2). There were no significant differences in atrial fibrillation recurrences between two groups (27 % vs. 33 %, p= NS).
This is the first study to assess the role of addition of ICE to fluoroscopy in patients undergoing CBA of AF. Procedure and fluoroscopy times were better in this study using ICE based CBA compared to TEE based CBA reported in previous studies. ICE based approach is especially helpful in patients with anatomic variations of pulmonary veins. ICE also helps in assuring contact of cryoballoon with tissue surfaces in areas that are hard to reach and engaging pulmonary veins and occlusion. There were no occurrences of phrenic nerve injury in patients assigned to ICE based approach in this study, however the study was underpowered to detect any differences. Results of this study should be viewed with caution since the operators were not blinded and the sample size was too small to make any conclusions regarding individual outcome differences.
Schmidt M, Daccarett M, Marschang H, Ritscher G, Turschner O, Brachmann J, Rittger H. Intracardiac echocardiography improves procedural efficiency during cryoballoon ablation for atrial fibrillation: a pilot study. J Cardiovasc Electrophysiol. 2010 Nov;21(11):1202-7.
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