755672
research-article2018
JDMXXX10.1177/8756479318755672Journal of Diagnostic Medical SonographyCone
Literature Review
The Role of Echocardiography in
Determining the Method of Ablation
for the Treatment of Paroxysmal Atrial
Fibrillation: A Literature Review
Abigail Krystal Cone, BS, RDCS1
Abstract
Atrial fibrillation is the most common cardiac arrhythmia, affecting approximately 1 out of every 250 people. It is
associated with thrombus formation in the left atrium, decreased cardiac output, and deterioration of the myocardium.
There are multiple treatments available for paroxysmal atrial fibrillation. This literature review will assess the benefits,
risks, and complications associated with radiofrequency ablation and cryoablation, which utilize heat and freezing
mechanisms, respectively. The review will also assess the role of echocardiography in determining which treatment, if
any, is appropriate for atrial fibrillation.
Keywords
atrial fibrillation, arrhythmia, ablation, echocardiography
Atrial fibrillation (AF) is the most commonly diagnosed
arrhythmia, with a prevalence of approximately 0.5% in
the general population.1 The incidence of AF is projected
to double from 2010 to 2030, by an estimated 2.6 million
cases, increasing total prevalence to 12.1 million cases in
the United States.2 This conduction abnormality is associ-
ated with thromboembolic events and decreased cardiac
function and can potentially reduce the quality of life in
some patients with symptomatic atrial fibrillation.3 As the
understanding behind the pathophysiology of AF devel-
ops and new techniques for treatment are introduced,
echocardiography has become an increasingly useful tool
for both determining which therapy is most appropriate
and ruling out a cardiac thrombus prior to cardioversion
or an ablation procedure. Two specific treatments are cur-
rently available, radiofrequency and cryoballoon abla-
tion, both of which create transmural lesions to disrupt
the arrhythmogenic foci causing AF.4 Depending on clini-
cal presentation and echocardiographic assessment, one
technique may be preferred over the other; therefore, it is
crucial for sonographers to become familiar with each
method and better understand the role of sonography in
evaluating for an ablation procedure.
Atrial Fibrillation
Atrial fibrillation is defined as a supraventricular tachyar-
rhythmia characterized by irregular activation of the atria.4
The primary mechanisms in initiating and maintaining
Journal of Diagnostic Medical Sonography
2018, Vol. 34(3) 209­–214
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DOI: 10.1177/8756479318755672
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atrial fibrillation are local ectopic firing and one or more
electrical reentry circuits in the atria or pulmonary veins.5
The mechanism employed can vary depending on the type
of AF, which can generally fall into one of three catego-
ries: paroxysmal (self-terminating), persistent, or chronic.4
Studies have shown that chronic forms of AF are more
resistant to remaining in normal sinus rhythm and patients
with chronic AF may not be viable candidates for an abla-
tion; therefore, this literature review will primarily focus
on paroxysmal atrial fibrillation.6
Treatment
Currently, two primary mechanisms exist for managing
AF: rhythm control and rate control.4 Rate control is a
pharmacological solution, which includes beta blockers
and calcium channel blockers, with the ultimate goal of
achieving a ventricular response rate of under 80 beats
per minute.5 Rhythm control is the preferred option for
patients who are symptomatic in AF and can refer to
cardioversion (either electrical or pharmacological),
1
Seattle Children’s Hospital, Seattle, WA, USA
Received March 14, 2017, and accepted for publication November 23,
2017.
Corresponding Author:
Abigail Krystal Cone, BS, RDCS, Seattle Children’s Hospital,
10538 Dayton Ave N, Seattle, WA 98133, USA.
Email: abigailcone9@gmail.com
210 Journal of Diagnostic Medical Sonography 34(3)
surgical, or catheter ablation. Surgical ablation is known
as the Cox-Maze procedure, also called the “cut and
sew” method.7 This surgery works by creating multiple
lesions in the atria to isolate the pulmonary veins, form-
ing a “maze” that disrupts the electrical pathways; how-
ever, this procedure is highly invasive and complex.7
The hybrid Maze procedure utilizes both extracardiac
surgical ablation as well as intracardiac catheter abla-
tion simultaneously.7
Catheter ablation is a relatively new technique in man-
aging arrhythmias; this method was first studied and uti-
lized to treat AF in 1998.8 As it pertains to AF, the purpose
of an ablation is to destroy the specific foci that are trig-
gering atrial fibrillation, which can exist in the left atrium
(LA), inside the pulmonary veins, or near the coronary
ostia.4 Radiofrequency and cryoballoon are two specific
modes of ablation that use different techniques to achieve
the same result: destruction of arrhythmogenic foci.
Ablation Techniques
Radiofrequency (RF), which is known as one of the first
energy forms utilized for cardiac ablation, cauterizes the
target cardiac tissue.9,10 Devices can be unipolar or bipo-
lar, which both utilize alternating currents, anywhere
from 100 to 1000 kHz, to create a transmural lesion to
disrupt abnormal electrical pathways.9 However, unipolar
RF ablations, which utilize a single electrode, have been
shown to be less effective; studies have estimated that
only between 7% and 20% of unipolar RF lesions are
transmural, increasing the risk of recurrent AF status post
ablation.9 Bipolar RF technology incorporates two elec-
trodes, either between the jaws of a clamp or side by side,
to create a therapeutic lesion.9 This technique is consid-
ered quicker and safer than unipolar RF ablation but is
not without risks. Major complications have been reported
in about 5% to 6% of bipolar RF ablations for AF, includ-
ing cardiac tamponade, thromboembolism, and perfora-
tion leading to an atrial-esophageal fistula.3
Cryoballoon ablation is performed by pumping nitrous
oxide under high pressure into a hollow balloon adjacent
to an electrode, where the liquid is converted to a gas; the
cryothermal energy produces ice crystals that disrupt the
cell membranes and destroy the myocardium.9,11 Unlike
RF energy, cryoablation does not affect tissue collagen,
making it preferable for arrhythmias that originate near
sensitive valvar tissue.9 However, one side effect of the
healing process after cryothermal injury is extensive
fibrosis; although this scar tissue has a minimal capacity
for conducing AF, currently cryoballoon ablation is
reserved for patients who have not undergone an ablation
before to prevent the buildup of fibrotic tissue.3,9
Studies comparing these techniques have varied
somewhat in their findings. A 2008 study performed on
Figure 1.  This transesophageal echocardiography image
shows a thrombus in the left atrial appendage.16
sheep paced into an artificial atrial fibrillation found that
while both modalities are equally effective in creating
transmural lesions, the RF bipolar clamp completed the
procedure faster, was reportedly easier to manipulate
than the cryoballoon, and reduced the potential risk of
adjacent injury.12 A larger clinical study, which was per-
formed between 2011 and 2014, compared pulmonary
vein isolation via cryoablation versus RF for atrial
fibrillation.13 This study found procedural time for cryo-
ballon ablation to be significantly shorter (by 80 minutes
on average), and the long-term success rates were 5%
greater than for the RF ablation group; however, the
cryoablation group also had a higher occurrence of
phrenic nerve palsy post procedure.13 A third study, per-
formed in 2010, compared the two techniques under
varying degrees of sedation and found that less analgesic
was required for cryoablation, decreasing the risk of
drug overdose.14 Additional studies have found no sig-
nificant difference between the two techniques for the
treatment of paroxysmal atrial fibrillation.15,16
Transesophageal Echocardiography
The loss of coordinated atrial contraction that is charac-
teristic of AF results in decreased diastolic filling and
blood stasis, which can lead to thrombus formation (par-
ticularly in the left atrial appendage; LAA) (Figure 1).17
Atrial fibrillation is considered the cause of almost half
of all thromboembolic events with a cardiac source.18
Transesophageal echocardiography (TEE) is the gold
standard for detecting LA or LAA thrombus prior
to radiofrequency or cryoablation for AF treatment
(Figure 2).19 Transesophageal echocardiography pro-
vides an excellent sensitivity and specificity for detect-
ing thrombus in the left atrium, of approximately 95% to
100%.18 Use of a microbubble contrast agent during TEE
Cone 211
Figure 2.  This transesophageal echocardiography image
shows an X-plane through the left atrial appendage (LAA).
X-plane allows for simultaneous biplane imaging through
orthogonal planes.
imaging, such as Definity or Optison, can also improve
thrombus detection. A study performed by Jung et al.20
found that contrast imaging could definitively exclude a
LAA thrombus in a greater percentage of patients (83.3%
vs. 66.7%). In the setting of an atrial arrhythmia, the
American Society of Echocardiography recommends
sweeps of the atria and atrial appendages as well as 3D
imaging with a high-frequency transducer to rule out
thrombus.21 This procedure is an important step in con-
firming the absence of clot in the LA and can potentially
determine which AF treatment will be utilized in the
short term. However, transthoracic echocardiography
(TTE) is a less invasive assessment of cardiac function
and offers additional information on which treatment
may be preferred.
Role of Transthoracic
Echocardiography
Transthoracic echocardiography provides an essential
evaluation of left atrial and left ventricular size and
function while potentially revealing any underlying
heart disease that may be a risk factor for AF, such
as rheumatic heart disease, mitral valve disease, or
ischemia.22 Left atrial size is a common predictor for
the effectiveness of an ablation; a 5 mm increase in
anterior-posterior (AP) dimension for the same patient
between exams is associated with a 39% greater risk for
developing AF for that patient, even status post ablation
(Tables 1, 2).18 However, AP measurements can easily
underestimate an oblong left atrium, and LA volume is
currently the recommended standard for a more accu-
rate measurement.18
Table 1.  Reference Values for Left Atrial Dimensions and
Volume for Women.23,24
Mildly Moderately Severely
Normal Dilated Dilated Dilated
Left atrium 2.7-3.8 3.9-4.2 4.3-4.6 ≥4.7
anterior-posterior
diameter (cm)
Left atrium 16-34 35-41 42-48 >48
volume/BSA (mL/m2)
Table 2.  Reference Values for Left Atrial Dimensions and
Volume for Men.23,24
Mildly Moderately Severely
Normal Dilated Dilated Dilated
Left atrium 3.0-4.0 4.1-4.6 4.7-5.2 ≥5.2
anterior-posterior
diameter (cm)
Left atrium 16-34 35-41 42-48 >48
volume/BSA (mL/m2)
Left atrial volume is typically measured using the
ellipsoid model, which takes both the area and length of
the atrium in an apical two and four chamber and calcu-
lates a prolate ellipse (Figures 3, 4).23 If the left atrium is
severely enlarged (greater than 5.2 cm AP for men, 4.7
cm for women or a volume greater than 79 mL for men,
73 mL for women), an ablation may not be recommended;
most of the studies performed excluded patients with
severely dilated atria (Figure 5). As the LA dilates with
recurrent AF, the relative position of the pulmonary veins
and the body of the left atrium may shift closer to the
esophagus, increasing the risk of creating an atrial-esoph-
ageal fistula; this risk is due to the relative relationship of
these structures in the thorax (Figure 6).25 However, if an
ablation is possible, a cryoballoon ablation is a safer
option as it carries a decreased risk of esophageal perfora-
tion compared to RF ablation.3
Another consideration prior to ablation is left atrial
function, which has been historically difficult to quantify
in the setting of AF due to the lack of atrial waveform in
mitral inflow patterns. Tissue Doppler imaging (TDI) has
emerged as a rhythm-independent method of measuring
atrial function.18 Tissue Doppler imaging quantifies the
low-velocity signals created by myocardial tissue move-
ment, which is typically used to assess diastolic left ven-
tricular function in adults (Table 3).26,27 The waveforms
associated with TDI represent much of the same informa-
tion gathered from mitral inflows; the e’ wave shows
early diastolic relaxation of the myocardium, the a’ wave
represents atrial contraction, and a positive systolic veloc-
ity shows myocardial contraction (Figure 7).26 These
212 Journal of Diagnostic Medical Sonography 34(3)

Figure 3.  This transthoracic image shows a left atrial volume

taken in the apical four chamber view.

Figure 6.  This image shows the relative position of the left
atrium to the aorta (Ao), esophagus (Eso), and pulmonary
veins.23

Table 3.  Normal Reference Range of Tissue Doppler Imaging

Values for Healthy Adults (Mean ± Standard Deviation).27

s’ (cm/s) e’ (cm/s) a’ (cm/s)

Septal velocity 8.1 ± 1.5 8.6 ± 1.9 9.5 ± 2.4
Figure 4.  This transthoracic image shows a left atrial volume Lateral wall velocity 10.2 ± 2.4 12.2 ± 3 11.3 ± 2.9
taken in the apical two chamber view.

Figure 5.  This transthoracic echocardiogram shows a grossly Figure 7.  This image of Tissue Doppler imaging from an
enlarged left atrium (LA) from an apical four chamber view. apical four chamber shows the e’, a’, and s’ waves.
Cone 213
Table 4.  Average s’, e’, and E/e’ Ratio Values (Averaged
From Annular and Lateral Tissue Doppler Imaging; Mean ±
Standard Deviation) for Different Age Ranges.30
35-44 y 45-54 y 55-64 y 65-75 y
s’ (cm/s) 9.4 ± 1.7 9.3 ± 1.7 8.9 ± 1.6 8.7 ± 1.6
e’ (cm/s 11.7 ± 2.2 10.5 ± 2.0 9.4 ± 1.8 9.0 ± 1.4
E/e’ mean 6.9 ± 1.5 7.3 ± 1.6 8.4 ± 2.4 7.6 ± 1.8
ratio (cm/s)
parameters can change with age, restrictive physiology,
or decrease in ventricular or atrial function (Table 4). A
mitral annular a’ wave of less than 4 cm per second is a
proven indicator of decreased LA function, which leaves
the patient at an increased risk of recurrent AF status post
ablation.28 Given this possibility, radiofrequency ablation
is likely a preferred treatment; if a patient has a greater
probability of reverting to AF, repeated RF ablations have
actually been shown to improve left atrial function over
time.29 Since cryoablation is typically performed only
once due to the risk of extensive fibrosis, a patient with
decreased left atrial function is not the best candidate for
a cryoballoon procedure.
A third echocardiographic assessment for AF ablation
is left ventricular diastolic dysfunction, which can be
another indicator of AF recurrence in patients undergoing
catheter ablation. Many of the same TDI parameters used
to quantify left atrial function can give information about
diastolic function since left atrial pressure and left ven-
tricular diastolic function are closely related; for exam-
ple, an E/e’ ratio of greater than 15 cm/s represents
abnormally high left ventricular filling pressures.30 A
2014 study used mitral annular TDI e’ wave velocity and
mitral inflow E wave deceleration time as a way to quan-
tify LV diastolic function prior to RF ablation.31 The
study found that rhythm-independent measurements of
diastolic dysfunction are associated with an increased
risk of recurrent AF after ablation.31 Although this study
is flawed in that it only considers one method of ablation,
a patient at high risk for recurrent AF is best treated with
RF ablation, as opposed to cryoablation, which can only
be performed once.
Conclusion
At present, echocardiography is considered a reliable and
effective imaging modality for determining the most
appropriate treatment in the clinical setting of atrial fibril-
lation. If an ablation is necessary in a patient with symp-
tomatic AF, radiofrequency and cryoablation have both
been proven to be safe and effective in the management
of AF. Small variations in echocardiographic appearance
may indicate a preference for one technique over another;
however, these changes do not occur in a vacuum.
Medical professionals should consider the larger picture
of clinical presentation when determining the most suit-
able treatment for the management of arrhythmias.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author received no financial support for the research,
authorship, and/or publication of this article.
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