Author + information
- Received August 15, 2016
- Accepted August 19, 2016
- Published online April 17, 2017.
- aDepartment of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
- bDepartment of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
- ↵∗Address for correspondence:
Dr. Uğur Canpolat, Department of Cardiology, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey.
A 68-year-old woman with symptomatic persistent atrial fibrillation (AF) despite the use of antiarrhythmic agents was hospitalized for catheter-based AF ablation. In our clinic, we empirically perform an additional left atrial appendage (LAA) isolation besides standard pulmonary vein isolation in all patients with persistent and long-standing persistent AF. After a single transseptal puncture, the 28-mm, novel, third-generation cryoballoon (CB-Advance Short Tip, Medtronic, Minneapolis, Minnesota) and the inner lumen circular mapping catheter (Achieve 15 mm, Medtronic) was advanced into the LA. After isolation of all the pulmonary vein potentials appropriately, the inner lumen circular mapping catheter was advanced into the LAA and then the CB3 was inflated and positioned at the LAA ostium aiming for complete occlusion (Figure 1A). During cryoballoon ablation, progressive LAA spike delay resulted in LAA isolation (time to block, 90 s; cryoballoon temperature, −47°C) (Figures 1B and 1C). Cryoballoon freeze was limited to 240 s, reaching a minimum temperature of −53°C. The left phrenic nerve, because of its proximity to the LAA, was monitored by fluoroscopy during spontaneous breathing. The ablation procedure was completed with no symptoms. Control coronary sine-angiogram after cryoablation revealed a vasospasm at the proximal segment of the circumflex artery (LCX) (Figure 1D). After administration of intracoronary nitrate, vasospasm was rapidly relieved (Figure 1E). Because of the close association between the LAA and the LCX, we retrospectively analyzed the pre-ablation computed tomography raw data, which confirmed the close proximity of the LCX to the LAA ostium (Figures 1F and 1G).
The LAA was shown to be a frequent non–pulmonary vein source and therapeutic target for left atrial arrhythmias in previous studies (1,2). However, there is debate regarding standard or empirical isolation of the LAA using catheter ablation technologies. In the recently presented BELIEF trial, Di Biase et al. (3) reported that empirical isolation of the LAA in addition to pulmonary vein isolation in long-standing persistent AF patients has significantly improved long-term outcome without an increase in complications (76% in the empirical LAA isolation plus standard ablation group vs. 56% in the standard ablation alone group at 24-month follow-up). However, all previous studies with LAA isolation have been performed by the radiofrequency technique. Recently, we presented our initial results with empirical isolation of the LAA in addition to pulmonary vein isolation using a cryoballoon technique in patients with persistent AF (with ∼65% acute success rate for LAA isolation) (4). Because of the safety concerns regarding thin-walled LAA isolation with the radiofrequency technique, we chose to use cryoballoon technology in our study. Although the LAA potential has been isolated successfully in our case, coronary vasospasm has occurred at the LCX just after cryoballoon application and was relieved by intracoronary nitrate. To the best of our knowledge, this case is the first description of vasospasm at the LCX during LAA isolation using the 28-mm CB3. The close proximity between the LAA and LCX place this latter structure and its branches at risk during procedures related to the LAA. This condition should be suspected if the patient develops signs of myocardial ischemia during isolation of the LAA using a cryoballoon catheter. Interestingly, our patient was asymptomatic both during and after the cryoablation procedure. Therefore, electrophysiologists may be advised to consider the possibility of LCX damage during isolation of the LAA, and simultaneous left coronary angiogram may be needed to calculate the distance between ablation lines and the LCX and its branches.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received August 15, 2016.
- Accepted August 19, 2016.
- 2017 American College of Cardiology Foundation
- Di Biase L.,
- Burkhardt J.D.,
- Mohanty P.,
- et al.
- ↵Di Biase L. Effect of Empirical Left Atrial Appendage Isolation on long-term procedure outcome in patients with Long-Standing Persistent AF undergoing Catheter Ablation: results from the BELIEF Randomized Trial. Available at: www.escardio.org/static_file/Escardio/Press-media/Press%20releases/2015/Congress/biase-belief.pdf. Accessed August 30, 2016.
- ↵Cardiac Rhythm News. Left atrial appendage isolation with cryoballoon may work as an adjunctive strategy for persistent AF treatment. Available at: https://cardiacrhythmnews.com/left-atrial-appendage-isolation-with-cryoballoon-may-work-as-an-adjunctive-strategy-for-persistent-af-treatment/. Accessed March 30, 2017.