Cryoballoon Ablation for Patients With Paroxysmal Atrial Fibrillation

Figures

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  Figure 1.. Comparison of the second-generation and fourth-generation cryoballoons (CB2 and CB4, respectively). The CB4 has a shorter tip to enhance visualization of pulmonary vein (PV) potential by enabling more proximal placement of the Achieve mapping catheter in the PV.

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  Figure 2.. Representative cryoballoon (CB) procedure in a patient with paroxysmal atrial fibrillation (AF). (A) A single transseptal puncture was performed using a radiofrequency (RF) needle (Baylis Medical, Montreal, QC, Canada) through an 8-Fr sheath (SL1, AF Division, Abbott/St. Jude Medical, Minneapolis, MN, USA) under intracardiac echocardiography (ICE) guidance (ViewFlexTM Xtra ICE catheter, Abbott/St. Jude Medical). (B) After transseptal puncture under ICE guidance, the SL1 sheath is advanced into the left atrium (LA) through the inner wire and pulled back into the right atrium (RA). (C) The FlexCath sheath is advanced into the LA via the transseptal puncture as a guide for the SL1 inner wire. (D) After the Optima mapping catheter is placed at the superior vena cava (SVC) through the SL1 sheath to observe the compound motor action potentials on the right side, the CB ablation procedure is started from the left superior pulmonary vein (PV), followed by the left inferior PV, the right inferior PV, and the right superior PV.

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  Figure 3.. Acute phrenic nerve palsy after cryoballoon (CB) ablation: chest X-ray (A) 1 day after and (B) 6 months after the CB ablation procedure.

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  Figure 4.. Representative case of severe spasm in the right coronary artery after cryoballoon ablation (CBA). (A) On surface electrocardiogram (ECG) the inferior leads showed ST-segment elevation, and emergency coronary angiography of the right coronary artery showed severe spasm. (B) After intracoronary injection of nitroglycerine, the right coronary artery spasm and surface ECG resolved. ISP, isoproterenol; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein.

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  Figure 5.. (A,B) After cryoballoon (CB) ablation, there were no residual pulmonary vein (PV) potentials inside any of the PV. Moreover, exit block to the left atrium (LA) was confirmed only in the right superior PV (RSPV). (C) A roving circular catheter recorded sporadic PV potentials from the right PV carina. (D) Additional radiofrequency applications around the right PV carina completely eliminated the conduction between the LA and right PV.