Intracardiac Echocardiography – guided Pulmonary Vein Isolation in Patients with Paroxysmal Atrial Fibrillation: Impact on Outcome and Complications

Sherif H. Zaky MD, Mostafa Alrefaee MD, Salah Atta MD, Hesham Hegazy MD, Jehan Abd Alhalim,MD, Laila Al-Hoty, NSc, Mahmood S Nsc.

From Babtain Cardiac Center, Dammam , Saudi Arabia Background: Pulmonary (PV) antrum ablation is considered the proper modality for electrical isolation of PV (PVI) and treatment of drug refractory paroxysmal atrial fibrillation (PAF). Conventional PVI using fluoroscopy alone can not guarantee neither the exact antral site of ablation nor the limit for radiofrequency power titration . The objective of this study was to assess the role of intracardiac echocardiography (ICE) for visualization & proper ablation of the PV antrum and its effect on both short-term success and incidence of complications in patients undergoing PVI for treatment of PAF. Patients and Methods: Thirty one patients (21 males, mean age 41.3+5.1 ys.) underwent PVI for treatment of PAF. Each patient underwent antral isolation of all PVs using an 8mm tip or irrigated tip ablation catheters. PVI was performed using electrophysiologic circular mapping (CM) alone (group1, 14 patients), CM and ICE (group 2, 17 patients) with titration of radiofrequency energy based on visualization of microbubble by ICE in case of group 2 or impedance rise in case of groop1. Pulsed wave Doppler was done before and after ablation of PVs in group 2 patients to assess for PV stenosis. Results: There was a significant difference between both groups in terms of mean fluoroscopy time (85 + 32 in group 1 vs. 61 + 44 min. in group 2, p< 0.05) and mean number of RF lesions per vein for complete isolation (15.5 + 2 vs. 8.5 + 2, P< 0.05) respectively. After a mean follow-up time of 12.5 + 2.3 months, 35% (5/14) of patients in groups 1, and 17.5% (3/17) experienced recurrence of AF, respectively (P< 0.05). Moreover, no one in group 2 patients experienced severe (>70%) PV stenosis postoperatively. Whereas, severe PV stenosis with dyspnea was documented in 3 out of 14 (3.5%) patients in group 1. No embolic events occurred in either groups. Conclusion: Use of ICE improves the outcome of PVI, reduces both fluoroscopy time and number of lesions per pulmonary vein. Power adjustment guided by direct visualization of microbubble formation reduces the lesions sufficient for complete PVI and thus risk of PV stenosis and improves short term cure. Key words : atrial fibrillation ablation – pulmonary vein isolation - intracardiac echo (ICE).

Radiofrequency (RF) catheter ablation has become first-line therapy for patients with drug-refractory atrial fibrillation (AF).(1,2) An early ablation strategy consisted of focal ablation of triggers inside the pulmonary veins (PVs) (3). To prevent complications of PV

In 8 patients laryngeal mask airway was not tolerated and required endotracheal intubation.All patients but 8 (4 in each group) received propofol/fentanyl induction of general anesthesia with laryngeal mask airway and spontaneous breathing of 60% oxygen in air supplemented with sevoflurane inhalation to deepen the anesthesia. muscle relaxation using atracurium and were mechanically ventilated . this method was modified to electrical isolation of the PV by segmental isolation at the ostium. Immediately before the procedure. invasive. The purpose of this study was to compare the efficacy and safety of PV isolation using circular mapping alone versus circular mapping with intracardiac echo (ICE) guidance in patients with paroxysmal AF and to assess the utility of ICE-detected microbubbles as a guide to RF titration. All patients were monitored by12 leads ECG . All patients signed a written informed consent .(9). Circular Mapping–Guided PV Isolation In all patients of both groups a decapolar coronary sinus catheter was inserted via right femoral sheath. The left atrium was instrumented using an 8 F sheath (Swartz SR0. effective ablation of cardiac tissue is dependent on the extent of contact between the ablation catheter tip and the endocardial surface. (8). arterial blood pressure and pulse oximeter monitoring .7) Phased-array intracardiac echocardiography has been shown to be helpful in defining right and left atrial structures most importantly the exact antrum of pulmonary veins. Antiarrhythmic drugs were discontinued at least 5 half-lives before the ablation procedure. We hypothesized that intracardiac echocardiography (ICE) would improve the success rates and minimize complications associated with PV isolation procedures by allowing real-time monitoring of both PV ostium and radiofrequency (RF) energy delivery.stenosis. Methods Patients Between December 2006 and june 2008. all patients were safely extubated and stayed under full monitored observation in the recovery area for at least one hour before shifting to the cardiac wards.(4. Paroxysmal AF was defined as self-terminating episodes lasting < 7 days. transcutaneous cardioversion/defiberllation pads placed prior to induction. transesophageal echocardiography was performed in all study patients to rule out any left atrial masses. We excluded Persistent AF which was considered when AF episodes lasted longer than 7 days and when pharmacological or DC cardioversion was needed to restore sinus rhythm and permanent AF defined as episodes failing cardioversion (1) Anaethesia workup : All patients were fasting before procedure.(6. 31 consecutive patients were referred to our laboratory for ablation of AF. In interventional electrophysiology procedures.5) Strategies evolved to include wide area encircling of the PV antrum using sophisticated three-dimensional mapping systems that could reconstruct atrial anatomy for guiding ablation and limiting fluoroscopy time. .

).St. Intracardiac Echocardiogram and Circular Mapping–Guided PV Isolation In group 2 patients (17 patients). The ICE catheter was connected to an ultrasound platform (Viewmate system). EP-med systems. The ICE catheter with bidrodirectional tip deflectability was introducedand. Pulsed-wave 3uperio flow velocities of all PVs were recorded before and after ablation to assess PV narrowing. The Lasso catheter was positioned at the pulmonary vein ostia under fluoroscopy guidance only in group 1 patients. a 9 F. The sheath was advanced to the left atrium again and wire replaced by a deflectable 3uperior3 circumferential catheter (LASSO) with deflectable ring diameter ranging from 15 to 25 mm. Two types of bubble patterns were seen with ICE: (1) scattered microbubble (type 1). Electrical mapping of PV and left atrial potentials was used to apply proximal lesions guided by PV potentials proximally recorded by Lasso catheter in the antrum of PV as defined by angiogram (At junction with appendage edge in case of left PVs. New Jersy) was introduced through a 10-Fr sheath via the left femoral vein additional to the previously described three catheters. An ablation catheter was passed through a third sheath in Rt. The ablation catheter was advanced to the left atrium through same transeptal puncture guided by the wire and fluoroscopy in LAO view. The PV angiogram was obtained in both 45-degree left anterior oblique and 30-degree right anterior oblique views (LAO). All PV ostia were defined after transseptal puncture .femoral vein via a trans-septal puncture if no patent foramen oval was found. Microbubbles Monitoring With Intracardiac Echocardiogram In group 2. and (2) brisk shower of dense microbubbles (type 2). All pulmonary veins were canulated with the sheath or an inner 6 F NIH catheter where PV angiography during adenosine-induced (range. Pulmonary vein ostia were localized by performing PV angiogram.5 m/sec. Twenty to 25 mL of manually injected contrast was used for each angiogram. . The electrophysiologist performing the mapping and ablation procedure optimized the ICE images. The trans-septal puncture was performed under ICE guidance to visualize the intra-atrial septum in group 2 patients. reflecting early tissue overheating (Figure 2). reflecting impending impedance rise (Figure 3). A guide wire (0. ICE was used not only to ensure circular mapping catheter positioning (Figure 1) and appropriate site of energy delivery but also to guide energy titration by monitoring microbubble formation. 64 element phased-array ultrasound imaging ICE–catheter ( (ViewFlex. 12 to 24 mg) asystole was performed.atrium.Jude) via Rt. or lateral border of ineratrial septum in case of right PVs. and ablation at the PV ostium was aborted when the PV diastolic flow velocity exceeded 1. RF energy was delivered using the same ablation catheters applying the ablation protocol described above for group 1 patients.035) was then advanced to the left atrium through the trans-septal sheath then sheath withdrawn to Rt. In group 2 patients.. fluoroscopically positioned in the right atrium. deflectable.femoral vein.

EP Technologies) or Irrigated tip 4 mm thermocool catheter. A 50°C was set as target in case of 8 mm tip catheters and in both a Stockert RF generator (Biosense Webster) was used. When the type 1 microbubble pattern was seen.2 Type 2 ( Localized) microbubbles during ablation at the ostium of the right 4superior PV (RSPV). Definition of Successful PV Isolation PV isolation was considered acutely successful after abolition of all ostial PV potentials recorded on the circular mapping catheter during sinus rhythm or coronary sinus and right atrial pacing LSP Fig. The Lasso catheter (arrows) is placed at the ostium of the vein . A 35°C target temperature was chosen for RF energy delivery through the cooled-tip catheter. watching for formation of type 1 bubbles only in the latter group while watching for impedance rise only in group 1. (Blazer. 1 Circular mapping catheter (Lasso) positioned at the ostium of the left superior (pulmonary vein (LSPV Fig.Protocol of RF ablation. Energy delivery was terminated when type 2 bubbles were seen. Ablation catheters used were either 8 mm Tip . power was titrated upward (5-watt increments). energy was titrated down by 5-watt decrements until microbubble generation subsided. (Bisense Webster ). Although we applied the same energy delivery protocol for group 1 and 2 patients.

( arrow at needle tip puncturing the inter atrial septum) LA: left atrium.4 Transeptal puncture under ICE guidance.3 Shower of dense microbubbles (type 2 bubbles) extending to the left atrial cavity observed during radiofrequency delivery at the ostium of the right superior pulmonary vein (RSPV). .Fig. Fig. RA right atrium.

For analysis.Age (ys Group 2 ((With ICE 11/4 2. anticoagulation and antiarrhythmic drug was stopped unless patients experienced recurrence of AF. Patients were also monitored with Holter recording before discharge and at 3. recurrence of AF was defined as AF occurring 8 or more weeks after the procedure. a standard heparin infusion of 10 U/kg/hour was initiated.8 + 2. y SHD .7 1.During the procedure.2 + 3.9 + 40. The lower level of anticoagulation should be maintained at an ACT of at least 250–350 seconds throughout the procedure. 3. Differences among groups of continuous variables were determined by ANOVA. After a loading dose of 100 U/kg. Continuous variables were compared by Student’s t test.5-3. Activated clotting times (ACT) was checked at 10. 6.1 3/17 Duration of AF.0) and one antiarrhythmic drug (either propaphenone or Amiodarone) for three months. Follow-Up Patients were discharged home the day after ablation. patients (male/female (. Follow-up was scheduled at 1. After 3 months. All patients were discharged on oral anticoagulation with warfarin (keeping INR at range 2.1 15-minute intervals until therapeutic anticoagulation is achieved and then at 30 minute intervals during the case.6 2/14 10/7 1.and 6-month follow-up. Categorical variables were compared by X2 analysis or with Fisher’s exact test. and 12 months after ablation. Statistical Analysis Continuous variables are expressed as mean±SD. systemic anticoagulation was achieved with intravenous heparin for all patients.3 + 43. Table 1 Patients' Demographics Group 1 (Without ICE) (No.

Type 2 bubbles preceded impedance rise by a mean of 3. use of AAD. in group 1 .LA size.). complications tended to be also lower with group 2 patients : ICE-Guided Ablation Monitoring : Type 1 bubbles were observed during all procedures of group 2 patients in 75% of the lesions delivered during PV isolation and led adjustment of RF power. in group2.5 + 4.5 + 2 ) versus 8.% Results : • Thirty one consecutive patients were referred to our laboratory for ablation of symptomatic paroxysmal AF (21 males. 3 to 5) and was always followed by a rise in impedance unless the power was turned off.2 11 + 53 0.5% of the left PVs (3 of 31). 61 + 44 min.05). It was evident that there was a significant difference in terms of fluoroscopy time (85 + 32min. in group 1 Vs.5 + 2 lesions per vein were given. Where procedure time was lower ( but not statistically significant) in group 2 (198 + 72 min.Ejection fraction .4 seconds (range. duration of AF.Structural heart disease was present in 5 patiens (16%). gender.5 + 2 lesions per vein in group 2 patients ( P< 0. mean age 41.6 + 4. Type 2 bubbles were observed during 43% of lesions delivered in group 2 .1 ys.3+5. In group 1 pts a mean of 15. The mean number of RF lesions per vein was higher in group 1 patients (15. or presence of Structural heart disease Pulmonary vein isolation : A total of 112 PVs in 31 patients were mapped and successfully isolated. The demographics of the study population are given in Table 1. There was no significant difference between both groups as regards age.5 + 2 RF lesions (range 6 – 21 lesions) per PV were delivered to achieve complete isolation. LA size. cm 0. .05) .5%) and in 10. A mean of 10. Table 2 depicts the acute results in both groups. On the other hand power titration for group 1 patients based on impedance rise was done for PV isolation in 88 % of lesions in group 1 patients.) Vs 261 + 54 min. p<0.3 7 + 54 SHD : structural heart disease LA : left atrium . A common PV ostium was found in 6 cases ( 3 pts on the right PVs (10.

min Mean No. The recurrence rate was higher in group 1 patients .= 14 No. Pulmonary Vein Isolation and Follow-Up Results Group 1 (Without ICE) Group 2 (With ICE) No. 8 out of the 31 studied patients ( 26%) experienced recurrence .5 + 2 NS NS NS 0.9 72 + 198 44 + 61 2 + 8.5 months .05). after a mean follow up period of 12.6 + 0.05 > NS AAD Procedure time. Complications included : one case with tamponade (group 1). RSPV A B (Fig. RF lesions/PV Follow-up.5 . min Fluoroscopy time. isolated PVs.Recurrence : As in Table 2 which demonstrates follow-up results. 5 Pulmonary vein angiography ( RSPV) before ( A) and at end of procedure(B TABLE 2.= 17 63 (17/15/17/14) 0.8 261 + 54 32 + 85 15. (LSPV/LIPV/RSPV/RIPV) No.05 > 0.P 49 (14/11/14/10) 0. 4 had significant PVstenosis (> 70%) detected by angiography at end of procedure (3 in group1). months 4 + 13 5 + 10 .4 + 1.5%) ( P < 0.5 + 1. PV stenosis tended to be higher in group 1 than group 2 although not statistically significant. 5 out of 14 ( 35%) in comparison to 3 out of 17 in ICE guided ablation group 2 (17.

05 > NS Complications ICE indicates intracardiac echo. RIPV. left atrium.(vein(RSPV A B . PV. and AAD. LSPV. left inferior pulmonary vein.6 Termination of an AF paroxysm during RF ablation of right superior pulmonary . RSPV. right inferior pulmonary vein.Recurrence of AF (35%) 5/14 (28%) 4/14 (17. antiarrhythmic drug Fig. LA. right superior pulmonary vein. LIPV.5%) 2/17 0. left superior pulmonary vein. pulmonary veins.5%) 3/17 (11.

5 %recurrence) in a comparable period of follow up. whereas Mangrum et al isolated only PVs triggering APCs and AF during the procedur. the poor contact between the ablation catheter tip and the endocardial surface reduces heat transfer to the tissue and allows convective heat loss into the circulating blood. Kalman et al (14) reported that less than 50% of fluoroscopically guided RF lesions were delivered with good perpendicular contact.C Fig. proves that ICE-guided pulmonary vein isolation is more effective than angiography-guided circular mapping. Circular mapping–guided PV isolation for treatment of AF has been reported to be effective and feasible. Diminished heat delivery to the PV ostial tissue may result in increased power output.(10. Second. inefficient lesion formation. monitoring of energy delivery using ICE additionally improved long-term success and was associated with decreased risk of complications. In addition.complete isolation note disappearance of PV potentials Discussion Our study despite limited number of patients. all PVs were isolated.(12. A) before isolation under coronary sinus pacing B) start of conduction block between atrial and PV potentials C) after . The superiority of ICE-guided PV isolation compared with angiography-guided isolation using circular mapping could be explained by 2 factors. Mangrum et al(15) reported their experience using radial cross-sectional intracardiac echocardiography to guide anatomically based ostial PV isolation and reported a recurrence rate of 36% after 13+7 months of follow-up in patients with paroxysmal AF. Ensuring stability and proper ablation catheter tip tissue contact using ICE might have played an important role in the cure of AF and in the development of severe PV stenosis in our study patients. 7 Left superior pulmonary vein (lspv) isolation. this might explain our higher success rate in group 2 patients (17. Electrical mapping of the sleeves using the circular catheter and direct visualization of the PV ostium (Figure 1) were enhanced by ICE. it appeared that angiography-based placement of the circular mapping catheter is less accurate than ICE-assisted positioning. In our study population. and increased risk of coagulum formation. First. .11). True ostial PV isolation requires abolition of all PV potentials that extend to the PV antrum proximal to the tube-like portion of the vein.13).

which could create the milieu for PV stenosis. Atrial fibrillation ablation: reaching the mainstream. . et al. These findings occurred with higher frequency when the electrode-tissue contact was suboptimal.98:1769–1775. prevention of a dense shower of microbubbles with ICE imaging also seemed to diminish the risk of embolic events in our patient population. Worldwide survey on the methods. . power. efficacy and safety of catheter ablation for human atrial fibrillation.Monitoring of Energy Delivery : Radiofrequency energy is conventionally delivered using temperature. 1998. Kalman et al (14) reported that showers of microbubbles and occasionally of coagulum preceded rises in impedance. Jais P. 2006. et al.111:1100–1105. 2. Of interest. In addition to improved short term success rates. and impedance monitoring. Chen SA. conventional RF energy delivery using a cooled-tip catheter is generally limited to a target temperature of 35°C. Cappato R. Colvin EV. we noticed microbubbles in 75% of lesions in group 2 patients coinciding with less pulses needed for complete isolation of pulmonary veins. ICE-guided PV isolation seems to be was more effective than conventional circular mapping–guided PV isolation in patients with AF with better initial outcome and less rate of recurrence. Study Limitations The limited number of patients and lack of random assignment to treatment groups could have affected our findings. Robbins IM. References 1. In the present study. Increase in impedance has been associated with increased risk of coagulum formation (12) and could be a sign of improper lesion formation. On the other hand. we increased the power based on objective findings. Using microbubble generation to guide energy delivery may optimize lesion formation ensuring effective energy delivery and avoiding tissues overheating. monitoring of microbubble formation using ICE during radiofrequency energy delivery decreased rate of complications namely thromboembolism and PV stenosis. et al. We had acquired an increased experience that may have resulted in improved technical expertise at performing circular mapping and ablation. Shah DC. Circulation. Circulation.29:523–537. Energy delivery is typically terminated after approaching programmed ablation time or after a sudden increase in impedance that suggests excessive tissue heating. 4. Conclusions This study has compared ICE-guided PV isolation to circular mapping–guided PV isolation in patients with AF. Mookherjee D. By using the ICE-guided microbubble monitoring strategy. given the similarity among the treatment groups in baseline characteristics. However. 1998. Pulmonary vein stenosis after catheter ablation of atrial fibrillation. In addition.Fisher JD. et al. Spinelli MA. Haissaguerre M. we feel this is unlikely. the first 14 patients undergoing circular mapping–guided isolation alone were among the learning curve and could have affected the outcomes reported. N Engl J Med. 2005. hence presumably better and effective lesions. Pacing Clin Electrophysiol. 3. In an experimental model.339:659–666. . Doyle TP. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. Calkins H.

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